
Class. 3\i \t?^ 
Book q )G B j 



EMERGENCY SURGERY 



SLUSS 



THE LEATHER BOUND SERIES 

OF 

MEDICAL MANUALS 



BINNIE. Operative Siirgery. Third Edition. By John Fairbaim Binnie, 
A. M., C. M. (Aberdeen) ; Professor of Surgery, Kansas State University; 
Member American Surgical Association, xiii+743 pages. Illustrated, 
by 678 Engravings, some of which are printed in colors. Flexible 
Leather, Gilt Edges, Round Comers. $3.00 

GREENE. Medical Diagnosis. Second Edition. By Charles Lyman Greene, 
M. D., of St. Paul, Professor of the Theory and Practice of Medicine in 
the University of Minnesota. With 7 Colored Plates and 241 other Illus- 
trations. i2mo. Flexible Leather, Gilt Edges, Round Comers. $3.50 

HUGHES. Compend of the Practice of Medicine. Ninth Edition. By Daniel 
E. Hughes, M. D., late Chief Resident Physician Philadelphia Hospital. 
Revised by Samuel Horton Brown, M. D., Assistant Dermatologist, 
Philadelphia Hospital. With Illustrations. 785 pages. Flexible 
Leather, Gilt Edges, Round Comers. $2.50 

KYLE. Manual of Diseases of the Ear, Nose and Throat. Second Edition. 
By John Johnson Kyle, B. S , M. D., CUnical Professor of Otology, 
Rhinology and Laryngology in the Medical College of Indiana; Otologist, 
Rhinologist and Laryngologist to the City Hospital, Indianapolis; 
Member of the American Laryngological, Rhinological and Otological 
Society. With 169 lUustratioas. Flexible Leather, Gilt Edges, Round 
Comers. $3.00 

SLUSS. Emergency Surgery. By John W. Sluss, A. M., M. D., Professor of 
Anatomy, Indiana University School of Medicine; formerly Professor of 
Anatomy and Clinical Surgery, Medical College of Indiana; Surgeon to 
the Indianapolis City Hospital. With 584 Illustrations, xii+692 pages. 
i2mo. Flexible Leather, Gilt Edges, Round Comers. $3.50 

STEWART. Manual of Surgery. By Francis T. Stewart, M. D., Professor of 
Surgery, Philadelphia Polyclinic ; Associate in Surgery, Jefferson Medical 
College, Philadelphia, etc. 504 Illustrations, ix+778 pages. Flexible 
Leather, Gilt Edges, Round Corners. $3.50 

THAYER. Manual of Pathology. 131 Illustrations. General and Special. 
By A. E. Thayer, M. D., Professor of Pathology, University of Texas; 
formerly Assistant Instructor in Pathology, Cornell Medical School. 
With 131 Illustrations. 711 pages. 12 mo. Flexible Leather, Gilt 
Edges, Round Comers. $2.50 

THORNDIKE. Manual of Orthopedic Surgery. By Augustus Thomdike, 
M. D., Assistant Surgeon to the Children's Hospital, Boston; Member 
American Orthopedic Association. 191 Illustrations. i2mo. Flexible 
Leather, Gilt Edges, Round Comers. $2.50 

*** Other Volumes in Preparation. 



P. BLAKISTON'S SON & CO. 
Publishers : : PHILADELPHIA 



EMERGENCY SURGERY 



FOR THE GENERAL PRACTITIONER 



BY 

JOHN W. SLUSS, A.M., M.D. 

PROFESSOR OF ANATOMY, INDIANA UNIVERSITY SCHOOL OF MEDICINE; FORMERLY PROFESSOR 

OF ANATOMY AND CLINICAL SURGERY, MEDICAL COLLEGE OF INDIANA; SURGEON TO 

THE INDIANAPOLIS CITY HOSPITAL; SURGEON TO THE CITY DISPENSARY; 

MEMBER OF THE NATIONAL ASSOCIATION OF MILITARY SURGEONS. 



WITH 584 ILLUSTRATIONS 
SOME OF WHICH ARE PRINTED IN COLORS 



PHILADELPHIA 

BLAKISTON'S SON & CO. 

1012 WALNUT STREET 
1908 



-<\ 



O^O- 



V 



Copyright, 1908, by P. Blakiston's Son & Co. 



Printed by 

The Maple Press 

York, Pa. 



DEDICATION 

TO MY PRECEPTOR, DR. E. B. EVANS, TYPE AND EX- 
EMPLAR OF GENERAL PRACTITIONERS, IN MEMORY OF 
DAYS SPENT TOGETHER, THIS LITTLE WORK IS INSCRIBED 



[USHARY of C0NGRESS5 

I, III igrtw iiiwmiiir'^'^ 



PREFACE. 



This is a Surgery for the general practitioner: written not to instruct 
his leisure hour, but in the hope sometime to serve as a guide oi^t of 
uncertainty in a time of stress. Its merits and demerits should be 
reckoned from that point of view alone. If, occasionally, the form of 
expression seems dogmatic, it merely comports with the constant aim 
to be practical; certainly that aim has denied any place to theoretical 
discussions and has curtailed reference to the various views of recog- 
nized authority. An absence of bibliography, it is hoped, therefore, 
will not be regarded as discourtesy to the many writers, teachers and 
practitioners whose ideas have been so freely appropriated. 

Among the text-books more constantly consulted are Senn's Practical 
Surgery, The American Text-book of Surgery, Walsham's Surgery, 
Treves' Operative Surgery, Lejars' Chirurgie d'Urgence, Veau's 
Chirurgie d'Urgence et Pratique Courante, Von Bergmann's Chirurgie 
and Binnie's Operative Surgery. 

The Annals of Surgery, the American Journal of Surgery, the Inter- 
national Journal of Surgery and the Journal of the American Medical 
Association have been prolific sources of information. 

For advice and aid in many ways in the preparation of this book, 
special thanks are due Drs. John J, Kyle, James H. Ford, A. W. 
Brayton and Gustav Bergener. The original illustrations are the 
work of Dr. Helen Knabe. 

To the publishers, through whose counsel and patient criticism the 
book has grown into its present form, a grateful appreciation is to be 
expressed. 

August 27, 1908. J. W. S. 



Vll 



CONTENTS. 



PART I. 

CHAPTER I. 

The General Practitioner as an Emergency Surgeon: His Duties 
AND Responsibility: Equipment i 

CHAPTER n. 
Emergency Antisepsis. Operation in a Private House 6 

CHAPTER HI. 
Anesthesia to 



CHAPTER IV. 
Sutures; Methods and Materials 19 

CHAPTER V. 
Drainage 25 

CHAPTER VI. 
Dressings, Bandages, Splints 28 

CHAPTER VII. 
Shock 42 

CHAPTER VIII. 
Hemorrhage 46 

CHAPTER IX. 
Wounds: General Principles ^ 59 

CHAPTER X. 
Wounds op Special Regions '69 

f CHAPTER XI. 

Gunshot and Other Wounds in Military Practice 109 

CHAPTER XII. 
Gunshot Wounds in Civil Practice 142 

CHAPTER XIII. 
Fractures 151 

CHAPTER XIV. 
Injuries to Joints 220 

CHAPTER XV. 

Injury and Repair of Tendons 250 

ix 



X CONTENTS. 

CHAPTER XVI. 
Injury and Repair of Nerves 260 

CHAPTER XVII. 
Abscess 278 

CHAPTER XVIII. 
Phlegmon: Acute Spreading Infections 322 

CHAPTER XIX. 
Acute Osteomyelitis » sss 

CHAPTER XX. 
Septic Arthritis 340 

CHAPTER XXI. 
Foreign Bodies 350 

CHAPTER XXII. 
Burns, Scalds and Frost-bite 366 



PART II. 

CHAPTER I. 
Tracheotomy, Laryngotomy, Esophagotomy 372 

CHAPTER II. 
Urgent Thoracotomy. Repair of Injury to the Lungs. Repair 
OF Injury to the Pericardium. Repair of Injury to the Heart. 
Puncture of the Pericardium 381 

CHAPTER III. 
Empyema — Purulent Pleurisy 392 

CHAPTER IV. 
Urgent Craniectomy; Trephining 400 

CHAPTER V. 
Mastoid Abscess 409 

CHAPTER VI. 
Laparotomy for Traumatism 417 

CHAPTER VII. 

Appendicitis; Appendiceal Abscess; Purulent Peritonitis. . . .^. . . 43^ 

CHAPTER VIII. 
Acute Intestinal Obstruction 456 

CHAPTER IX. 
Artificial Anus; Temporary, Permanent 465 



CONTENTS. XI 

CHAPTER X. 
Str.\xgulated Hernia 474 

CHAPTER XL 
Radical Cure oe Inguinal Hernia . 503 

CHAPTER XII. 
Radical Cure oe Femoral Hernia - - - 5^3 

CHAPTER XIII. 
Enterectomy. Intestinal Anastomosis 519 

CHAPTER XIV. 
Impertorate Anus 530 

CHAPTER XV. 

Torsion oe the Pedicle oe Ovarian or Uterine Tumors; oe the Sper- 
matic Cord; oe the Pedicle of the Spleen; of the Omentum 535 

CHAPTER XVI. 
Rupture and Hemorrhage of Tubal Pregnancy 543 

CHAPTER XVII. 
Cesarean Section . 550 

CHAPTER XVIII. 
Rupture of the Urethra 554 

CHAPTER XIX. 
Acute Retention; Catheterization; Supra-pubic Puncture; Cystotomy; 
Urinary Infiltration 565 

CHAPTER XX. 
Suture and Ligation of Arteries 584 

CLIAPTER XXI. 
Practical Amputations 595 

CHAPTER XXIL' 
Dilation of the Sphincter Ani; Operation for Piles; Operation for 
Anal Fistula 649 

CHAPTER XXIII. 
Phimosis; Paraphimosis; Circumcision; Hydrocele; Castration 656 

CHAPTER XXIV. 
Ingrowing Toe-nails 667 

CHAPTER XXV. 
Removal of Small Tumors 670 

CHAPTER XXVI. 
Skin Grafting 673 

NDEX ------------------------------ 676 



, 



EMERGENCY SURGERY. 



CHAPTER I. 



THE GENERAL PRACTITIONER AS AN EMERGENCY 

SURGEON: HIS DUTIES AND RESPONSIBILITY. 

EQUIPMENT. 

Surgery is no longer reserved to the elect few. That its beneficence 
shall be denied a place in every practitioner's art is repugnant to the 
spirit of the times. Modern life is complex: every profession and 
every calling has its specific duty to perform. Whether the medical 
profession shall continue to play nobly its large part in the social 
drama depends upon the general practitioner. The hope of the 
profession rests in him. But there is a price to pay the age for high 
respect. That price to the medical profession is nothing less than the 
fulfillment of its therapeutic promise and the realization of its surgical 
opportunity. The opportunity is golden; for with the wonderful 
improvements in surgical technique, the field of emergency surgery, 
that is to say, the indication for immediate intervention, has been 
remarkably broadened and the time finds the public singularly favor- 
able to that form of relief. 

The "horror of the knife," of all that pertains to surgery, has 
become a tradition, like the practice which gave it birth. Indeed the 
public is trained to expect that in the face of grave emergencies, the 
practitioner will do something effective; however serious the required 
intervention may be, if it but offers hope, the doctor is expected to act. 
Our predecessors — even those able and willing — often found their 
hands tied under such circumstances by the ruling policy of "let 
alone and let die." It is a part of their glory that they conceived, 



2 THE GENERAL PRACTITIONER AS AN EMERGENCY SURGEON. 

planned, and attempted in the face of tremendous obstacles, most of 
the interventions of urgency which are current today. 

The surgical opportunity, then, of the general practitioner is clear, 
and his duty as well. The professional spirit, the humanities, his 
conscience, make it incumbent upon him to know and act. This 
he must do or drop to the rear in the march of progress, which does not 
halt for the timid or unwilling. 

But the task imposed is heavy, the responsibility large; for the gen- 
eral practitioner often finds himself isolated, remote from special 
counsel, perhaps compelled to act alone. That he does not always 
rise to the surgical emergency and do all that he might do even under 
unfavorable circumstances, may often be laid in large part at the door 
of his training. He knows often what he ought to do, yet knows not 
how to do it. Happily the courses of instruction are now generally 
planned to do away with this strange antithesis between theory 
and practice: a theory, modern, scientific, positive; a practice, as 
Lejars says, still often full of error and based on empiricism 
age-old. 

But this must not be; for now that the indications for operation are 
exactly defined and one's duty obvious, vague conception of an opera- 
tion as something far away and desperate, must give way to clear 
notions of the resources of surgery, of surgical therapeusis. Every 
doctor must familiarize himself wdth the technique of interventions 
which he must undertake at times, if he is not to be inexcusably remiss 
in an almost sacred duty. 

Surgery in one respect is a handicraft, and as such requires its certain 
tools of first necessity. If, as has been said, emergency surgery always 
comes in the nature of a surprise, then the surprise will at least be less 
complete if one has an equipment and has it prepared. 

Every doctor should have an emergency bag supplied with mate- 
rials: hand brushes, soap, a fountain syringe, hypodermic syringe, 
catheters, flasks of alcohol, ether, chloroform and carbolic acid, bi- 
chloride tablets, a package of sterile compresses, sutures, bandages, 
a box of Plaster-of-Paris and certain instruments. 

Hand Brushes. — These are almost indispensable for emergency sur- 



EQUIPMENT, 3 

gery. They should be kept wrapped in the case and sterilized before 
using. If necessary one may scrub the hands and field of operation 
with sterile gauze. 

Fountain Syringe or Irrigator. — One may use the full rubber out- 
fit or, w^hat is better, a porcelain container and a long rubber tube 
with glass nozzles. It is absolutely essential that the whole be steril- 
ized by boiling. It is nonsense to sterilize, as is often done, the 
canuloe and container and neglect the tube. The glass nozzles are 
likely to be broken if plunged directly into boiling water or if cooled 
too rapidly. If the porcelain container is used it may be boiled and 
then singed with burning alcohol. It takes up but little room in the 
bag, and the tube and nozzles may be wrapped up and packed in it 
and the whole wrapped and kept clean and dry. This outfit is almost 
indispensable, for in many emergencies the only adequate treatment 
is by hypodermoclysis or intravenous infusion. 

The Antiseptics. — The alcohol must be kept in a well stopped flask 
and the carbolic acid or lysol, also. The bichloride may be in the 
form of tablets, so that the strength of a solution may be readily cal- 
culated. The most commonly employed is the formula containing, 
mercury bichloride 7.3 gr., citric acid T)-^ gr. This tablet in one quart 
of water makes a 1 to 2000 solution, which is as strong as need be 
used. One to three pints makes a i to 3000 solution and so on. In- 
stead of the tablets one may keep a concentrated solution of 
bichloride in alcohol. 

Bichloride of Mercury, 5 j- 

Alcohol, § j. 

One teaspoonful to a quart of water makes a i to 2000 solution; 

One teaspoonful to 3 pints, i to 3000, etc. 

Anesthetics. — One should keep on hand at least one pint of ether 
and four to six ounces of chloroform. Cocaine for local anesthesia 
is best kept in tablet form and the solutions made extemporaneously. 

Sterile Gauze. — Too frequently the practitioner commits the error 
of depending upon absorbent cotton for his sponges and compresses. 
Absorbent cotton, as found on the market, is scarcely ever aseptic. 
Even if it is, it is almost certain to be contaminated in getting it out 
of the package. A supply of sterile gauze is one of the best means of 



4 THE GENERAL PRACTITIONER AS AN EMERGENCY SURGEON. 

promoting an aseptic operation. It should be kept in a hermetically 
sealed package of metal or glass. 

In lieu of the gauze compresses ready sterilized, one may carry a 
supply of ordinary gauze which can be cut into appropriate sizes, and 
sterilized at the time of operation. It is a good idea to cut two sizes; 
a small for compresses and wipers, a larger to cover the field of opera- 
tion. All these pieces should be folded once and the borders hemmed. 
A ball of cotton may be hemmed in between the layers, which makes a 
still better sponge. 

Sutures and Ligatures. — If these materials are not already steril- 
ized and in a special package, catgut must be ruled out, for its prep- 
aration takes too much time. One should take care to have several 
sizes of silk, especially the O and OO, for these are the sizes required 
in intestinal work. 

Catheters and bougies should be kept in a metallic box. Rubber 
and metal catheters are always readily sterilized by boiling. 

Drainage Tubes. — These should be preserved in a box or bottle 
which may be boiled thoroughly before opening. 

Plaster should be kept in a tin box with tight cover and may be 
loose or already rolled. A supply of roller bandages is, of course, 
always kept on hand from which the plaster bandages may be made. 

Instruments. — Any list which might be enumerated must, of course, be 
subject to the widest variation. But the feeling of greatest confi- 
dence goes w^ith the consciousness of having the necessary things 
with which to act. On the whole, the doctor should pride himself 
upon the completeness of his outfit rather than upon his ability to 
improvise. One should have as the minimum: scalpels, two sizes 
of amputating knives, scissors, grooved director, dissecting forceps, 
artery forceps — the more the better — two retractors, a saw, a bone 
chisel, needle holder and needles, tracheotomy tubes, and an Esmarch 
tube. The instruments most frequently used may be put together in 
a small metal case, while the others may be kept in larger cases or 
wrapped, or rolled up in a bundle. 

Cleaning instruments and preserving them from rust is a matter of 
no small importance. After each operation they should be taken 
apart, scrubbed with soap and warm water, wiped with gauze satu- 



CLEANSING INSTRUMENTS. 5 

rated with alcohol, and dried thoroughly. "If the cleansing has been 
delayed, it may be necessary to immerse them for a short time in a 
solution of potash and finally cleanse in the manner described. If 
any stains still persist they should be polished with chamois skin. 
Too often the practitioner neglects his instruments because, perhaps, 
not often used, and in the emergency he finds himself with knives 
rusty and without an edge, scissors that will not cut, and forceps that 
have no grip. He will certainly gain time by spending a little time in 
carrying out these small details. 



L 



CHAPTER II. 

EMERGENCY ANTISEPSIS. OPERATION IN A PRIVATE 

HOUSE. 

The preparation for an urgent intervention outside of an operating 
room resolves itself into a question of asepsis or antisepsis, and around 
this point gathers a multitude of details. But it is necessary only to 
proceed systematically and intelligently to achieve excellent results. 

The time was when the idea prevailed that an aseptic operation 
was scarcely possible outside a hospital. This was a harmful notion 
which restrained many a practitioner from an effort that might have 
saved his patient's life. Every day it is demonstrated that aseptic 
work is not peculiar to formal operating rooms. 

Bonney, of Philadelphia, writes that he has done many major opera- 
tions in the homes of the poor in the midst of the most unsurgical 
surroundings; nevertheless, the results have been excellent. Most 
of these operations were for urgent abdominal, pelvic, or genito-urinary 
disease, and though such w^ork is often time-consuming and laborious, 
yet it shows what can be done in the case of necessity. Bonney at- 
tributes his success with inflammatory conditions to complete removal 
of diseased tissue and free drainage in pus cases. 

Van der Walker (Month Cyclopedia of Pract. Med., Aug., [906) 
says that for thirty years he has operated in farm houses throughout 
central New York with as good results as those obtained in the 
hospital with which he was connected for many years. He goes 
further and concludes that for many reasons, it is desirable that there 
should be a return to more home operating, and that the hospital 
ought to go back to the original purpose, the care of the homeless and 
sick poor, and not invade the home with the arrogant assurance that 
only within its walls can the surgical case be cared for. 

But this is aside from the main point: the practitioner may jeel 

6 



PREPARATION OF THE ROOM. 7 

assured that with decision, knowledge and system, even under apparently 
imjavorahle circumstances, he can nearly always realize an effective 
asepsis. 

As Lejars says, everywhere one finds water, fire, and linen; add salt 
and usually carbonate of soda: with these one may accomplish a 
sufficient sterilization of the instruments, the hands, the field of opera- 
tion and the dressing. But it requires a will to do all the work, to 
proceed with method and, above all, quickly, through the minutia} 
of preparation. One should have a plan in mind and Lejars offers a 
model which, of course, can be modified to suit the circumstances 
and the operation. Suppose a major emergency, with every detail of 
the preparation to be supervised: 

First Step. — Have a fire started. Have the available receptacles 
assembled. Review the stock of linens if you do not have gauze 
or muslin. Freshly laundered handkerchiefs and napkins (without 
fringe) furnish material for excellent compresses and coverings 
for the field of operation. Secure one or two large kettles — a copper 
wash-boiler — for boiling the water for the operation. Secure three 
smaller receptacles such as enameled stewing-pans; one for boiling 
the instruments and sutures, another for the brushes, irrigator, nozzles 
and tube, etc; the third, for the compresses and tampons. If pos- 
sible boil also the dishes or basins selected to hold the instruments and 
the solutions needed during the operation. It is best to have a dish or 
bowl for the instruments, one for the tampons and compresses, one for 
the sutures, and two hand basins for sterile water and bichloride solu- 
tion. The boiling must be prolonged at least a half hour to be sure of 
sterilization. It is a good plan to add a teaspoonful of salt to the 
quart of water containing the compresses which are to be tied up 
in a towel to facilitate their removal; and to add a teaspoonful of 
washing soda to the water in which the instruments are to boil. The 
instruments ought not to be put in until the water is boiling, as other- 
wise they are likely to be tarnished. When once the sterilization 
is under way proceed to the operating room. 

SecondStep. Prepare the Operating Room and Table. — If there is any 
choice select the best lighted and largest room. If it is at night arrange 
for the illumination. Do not displace the furniture except to make 



8 EMERGENCY ANTISEPSIS. 

room for the operating table, two small tables, and room to "turn 
about." An extensive "clearing for action" does more harm than 
good, for by jerking down the curtains, rolling the furniture around 
and sweeping, one stirs up the dust, accumulating perhaps for months. 

It is preferable simply to sprinkle the floor or wipe with a wet cloth. 
To be sure if one has several hours in which to prepare, then the room 
may be emptied, the floor covered wath moist sheets and the walls 
sprayed, as Quenu suggests, with peroxide; the tables placed and the 
room closed until the time of operating. 

It is never a good idea to use the patient's bed for an operating table. 
The dining table can usually be pressed into service, covered with a 
blanket and that with an oilcloth. A table may be improvised from 
two wooden trestles with planks laid across and covered like the table. 
Of the two small tables required, the one on the assistant's side will 
hold the compresses, sutures, etc.; the other on the operator's side 
will hold the instruments. 

Now give the patient the preliminary preparation. Shave the parts, 
if necessary, and if the operation is likely to be prolonged, wrap the 
lower limbs in blankets. 

Third Step. — Everything having boiled sufficiently, carry the vessels 
into the operating room and empty the contents of each into its special 
receptacle. 

If these bowls have not been boiled now is the time to sterilize 
them by singeing with burning alcohol. Into each pour two or 
three spoonfuls of alcohol and set it on fire, in the meantime tilting the 
dish in various directions so that the flame is brought in contact with 
the whole inner surface. W hen this is done, lift the compresses and 
instruments out of their boilers, place them in these sterile dishes and 
cover them with an antiseptic solution. This protects them from 
possible contamination until the operation begins. Do not open the 
bag of compresses till needed. Remember to use only a sterile dipper 
if necessary to dip out the sterile water in preparing the various so- 
lutions. 

Fourth Step. — Direct the assistant to begin the anesthesia, and now 
prepare your hands. As Lejars remarks, this is a "science and art," 
the first duty of the surgeon. They are not to be prepared by a desul- 



PREPARATION OF THE HANDS AND FIELD OF OPERATION. 9 

tory rinsing in soapy water, or parboiling with a hot antiseptic solu- 
tion, but by a patient and systematic scrubbing. Get your sleeves 
rolled up and pinned. Have before you two wash basins, one with 
hot and the other with cold sterile water. Pare the nails. Begin 
with soap and hot water. Lather the arms up to the elbow, and rub 
the soap in until the skin seems saturated and soft. Then begin with 
the brush; scrub the palms, the dorsum of the hand, between the fin- 
gers, all about the nails. One need not rub the skin off, to be sure, 
but continue the scrubbing for at least ten minutes, having the water 
changed several times; next rinse in the cold sterile water and then 
rub vigorously with alcohol to remove all the oils in the skin; finally 
soak in bichloride solution. 

Fifth Step. — In the meantime the anesthesia has progressed. Pre- 
pare the field oj operation, by scrubbing with soap and water, followed 
by alcohol or ether and bichloride solution. 

The disinfection of the skin must be, in every respect, as thorough and 
vigorous as that of the hands, and must extend well beyond the proposed 
line of incision in all directions, for one can never tell where the incision 
may finally end. 

Again wash your hands. An untrained assistant changing the 
bowls may spoil the sterilization by getting his fingers or thumbs 
inside. Direct him how to lift and carry a bowl with his palms against 
the outside. 

Having .completed the final cleansing of the hands, cover the field 
of operation on the four sides wdth four sterile towels or large com- 
presses and fasten them with sterile safety pins or artery forceps. 

Time gained by relaxing in the least any of these precautions of 
asepsis and antisepsis, is irretrievably lost; it is the operation, now 
begun, which must progress rapidly. 



CHAPTER III. 
ANESTHESIA. 

Anesthesia is necessary in most emergency operations, not only to 
obviate pain, but because it is often essential to a good operation. 
Unfortunately, on the other hand, it adds to the doctor's task and pre- 
sents some special difficulties. 

In certain grave conditions, as intestinal occlusion, strangulated 
hernia, or abdominal traumatism, it may be the actual cause of death, 
however carefully administered. 

Not only in emergency work, but in any case, general anesthesia 
should be cautiously induced and narrowly watched, and for this 
reason it is especially embarrassing to the doctor compelled to entrust 
it to the untrained in cases of urgency. 

Chloroform has the advantage that it requires no special apparatus 
for its administration; and the smaller bulk is an item of importance, 
especially in military practice; moreover, it is much more pleasant to 
the patient. Unfortunately, it is many times more dangerous than 
ether, even in the hands of the skilled. 

In lieu of a special inhaler, such as Esmarch's, fold a handkerchief, 
napkin, or compress several times to- form a square. Begin by pouring 
on several drops and gently approaching it to the mouth and nose of 
the patient. The inhaler should be managed with the left hand, 
leaving the right hand free to raise the eye-lid, or feel the pulse, or handle 
the container. Do not hold it too close to begin with, but give the 
patient plenty of air; in other words, give the chloroform wxll diluted. 
Give the patient time to get accustomed to the odor. Advise him to 
breathe through the mouth and distract his attention as much as possi- 
ble; get his confidence, flatter him, and, in the meantime, study him and 
test him. The few minutes spent in this way will soon be regained. 

Pour on five or six drops of chloroform at a time, and as the respira- 
tion becomes deeper hold the inhaler closer, giving the chloroform less 

lO 



CHLOROFORM ANESTHESIA. II 

diluted with air. Replenish the supply every half minute, sprinkling 
it on the under side of the compress and quickly inverting it over the 
face. 

As the stage of excitement comes on, push it more. When the 
anesthesia is complete, reduce the dosage but increase the frequency 
of renewal. 

The drop method is ideal after the anesthesia has been attained. 
Small doses frequently applied mean the smallest total amount, which 
must be the anesthetist's constant aim. 

The good anesthetist is not the one who can use the largest amount 
of chloroform without death, but the one who can hold the patient 
merely unconscious and relaxed with the smallest amount possible. 

If the patient coughs or shows signs of nausea, increase the dosage 
at once. Do not begin the preparation of the field or any part of the 
operation until the anesthesia is complete. 

Keep the pulse, the pupil, the face and the thorax under constant 
surveillance, for in this way alone may one determine the prognosis, 
good or bad, of the anesthesia. 

The anesthesia is usually described as occurring in three stages: 
the first, stage of excitement; the second, loss of consciousness; the 
third, loss of reflexes or stage of surgical anesthesia. There is a fourth, 
stage of paralysis of the automatic centers, but this is a stage which the 
good anesthetist will never reach. 

The excitement of the initial stage, in which the patient struggles 
or talks at random, is followed by loss of consciousness, but the reflexes 
are active, the pulse is full and bounding, the pupils respond to light, 
the eye-lid resents the corneal touch, the skin is sensitive, the face is 
flushed and the breathing deep and regular. 

Beware at this time of sudden blanching of the face, of dilated pupils, 
of weakened pulse or disturbed breathing. If these symptoms arise, 
withdraw the anesthetic and prepare for artificial respiration. The 
patient is not ready for the operation and yet he may die in this 
stage. 

Often pallor and dilated pupils precede vomiting, but when the jnilse 
and respiration are good, the nausea is to be quieted by more chloroform. 

When the reflexes are finally abolished, the pulse should be full, 



12 ANESTHESIA. 

though perhaps a little slowed, the respiration quiet. and regular, the 
pupils slightly contracted and the face moderately pale. Any marked 
deviation from this standard during the operation is a matter for con- 
cern. 

Weak heart action, uncertain respiration, dilated pupils, deep 
pallor or cyanosis, mean approaching paralysis of the automatic cen- 
ters governing the circulation and respiration, and the anesthetic must 
be withdrawn until the symptoms improve under measures employed 
to stimulate. 

In the case of the average adult, one and one-half to two ounces 
should be sufficient for the first hour and much less subsequently. 
Children and the debilitated require less. 

Ether has the disadvantages in emergency work that it is dangerous 
to use near a light or fire and that its administration is a little more com- 
plicated, but beyond that, its anesthesia is never attended by sudden 
death in the early stages as is that of chloroform. It is followed by less 
shock after abdominal operations or other prolonged intervention. 
Bronchial affections are its chief counterindications. An inhaler may 
be fashioned out of a newspaper rolled into a cone, cotton or gauze 
being fastened in its apex, on which the ether is poured. Begin with a 
drachm; let the patient get accustomed gradually to the ether, diluting 
it well with air by holding the inhaler an inch or so from the face 
and gradually approaching. In that way, the feeling of suffocation is 
avoided. As the patient approaches unconsciousness, hold the mask 
closely so as to shut out the air, and the stage of anesthesia will be 
quickly reached without excitement. 

If one proceeds timidly at this stage, the anesthesia will be hard to 
obtain and much .more ether will be required. Once the reflexes are 
abolished, use small quantities, frequently applied. The "drop 
method " may be employed with ether as well as with chloroform, 
and reduces the danger to the minimum. The accident most to be 
feared is respiratory paralysis. 

The signs indicating the favorable progress of ether anesthesia during 
the operation are: pulse full and regular; respiration deep and slightly 
snoring; face flushed; and pupils slightly dflated. Cyanosis is the 
signal for more oxygen. Any disturbance of the respiration demands 



ACCIDENTS OF ANESTHESIA. 13 

immediate attention. For excessive mucous formation Ford recom- 
mends spraying on the mask at intervals of five or six minutes when 
necessary an adrenalin solution. Three parts of water to one part 
adrenalin solution (i-iooo> are used in an ordinary atomizer. Ford 
claims that it also acts as a circulatory stimulant. 

TREATMENT OF THE ACCIDENTS OF 
ANESTHESIA. 

Certain measures are recommended as forestalling the dangers, 
of anesthesia though they are, as a rule, more appropriate in the general 
surgery of hospitals. 

A preliminary gastric lavage will save embarrassment in certain 
cases. A preliminary subcutaneous injection of normal salt solution 
wdll sustain the patient in the cases of anemia and grave septic infection. 

Many surgeons precede a chloroform anesthesia by hypodermic 
injection of morphia or strychnia. None of these methods lessens the 
anesthetist's responsibility and duty to watch every point. 

If the circulation grows weak, the pulse small, rapid, compressible, 
due to the effect of the anesthetic agent and not to shock or hemorrhage, 
withdraw the agent and lower the head, draw out the tongue and begin 
artificial respiration, and the danger is usually soon passed. 

Hypodermic injection of stimulants, such as strychnia or camphorated 
oil, often do good under these circumstances ; but when the circulation 
is paralyzed and syncope has supervened, their use is illusory. Do 
not w^aste time preparing them, though an assistant may do so, but 
proceed to make rhythmic traction on the tongue, and artificial respira- 
tion, both being carried out methodically. If an assistant is at hand, 
carry out the two measures simultaneously; otherwise, try the tongue 
traction first or at least get it pulled out well. Traction of the tongue 
to do good, must be rhythmic. The tongue must be caught up care- 
fully with forceps and no force must be used. Often the tongue is 
seriously injured by the feverish pulls of the agitated operator, who 
has quite forgotten that the maneuver is effectual only when rhythmic. 
Likewise, the artificial respiration must be rhythmic. 

Grasp the patient's elbows and draw them gently and steadily up- 



14 



ANESTHESIA. 



ward until they meet above the head. The pectoral muscles are put 
upon" the stretch and the chest expanded and respiration produced. 
At the same time the tongue is drawn outward (Fig. i). 

The arms are next brought with a steady movelrftht to the chest 




Fig. I. — Stage of inspiration. Tongue shouiva be drawn out with this movement. (Stewart.) 

wall and the diaphragm compressed. (Stage of expiration.) At 
the same time, the tongue is permitted to retract (Fig. 2). 

These movements are to be repeated at the rate of about twenty 




Fig. 2. — Stage of expiration. Tongue permitted to drop back in mouth. (Stewart.) 



per minute and should be persisted in without intermission for at least 
a. half hour before giving up hope of resuscitation. 

Direct compression of the heart is a procedure of real value and it 
may often be readily managed through the abdominal walls. In the 



LOCAL ANESTHESIA. 



15 



case of abdominal operations, the hand may be passed up to the dia- 
phragm and the heart seized and kneaded in that manner. 

Other forms of general anesthesia will not often be of service in 
emergency practice for obvious reasons, however valuable they may 
otherwise be. It is hardly necessary, therefore, to consider nitrous 
oxide or ethyl chloride and their congeners. 

LOCAL ANESTHESIA. 

The doctor, isolated and without assistants, will many times find 
aid and comfort in local anesthesia by hypodermic injection; but to be 
efficient, it must be properly induced. A definite technique must be 
followed. Either cocaine or stovaine may be used, the latter safer, the 
former slightly more active, the two used alike. Having determined 




Fig. 3. — Local anesthesia; method of introducing needle. (Veau.) 



the line of incision, pinch up a fold of skin (Fig. 3), introduce the needle 
at one end of the line and push it into the skin but not through the skin. 
The injection is intradermal (Fig. 4). As the needle is steadily ad- 
vanced, the syringe is emptied slowly and the line of injection is in- 
dicated by the formation of a wheal. When the needle has entered 
its length, it is reintroduced in the same line and in advance of the pre- 
vious puncture, but within the area already anesthetized. In this way, 
only the first puncture is felt. When the line of incision has been in- 
filtrated in this manner throughout its entire length, it will be com- 
pletely insensitive after a wait of one to two minutes. The width of 
the zone of anesthesia will depend upon the rate of movement of the 
needle through the skin (Figs. 5, 6). It need hardly be said that the 



i6 



ANESTHESIA. 



needle and solution must always be sterile. It is better to pour the 
solution out into a sterile dish or glass, rather than to aspirate it from 
the bottle. The air must be forced out before the needle is introduced; 
care must be taken not to throw the injection into a vein. 







Fig. 4. — Local anesthesia; the needle does not penetrate the whole 
thickness of skin; "intra-dermic" injection. (Veau.) 

When an area, rather than a line, is to be infiltrated, in a case where 
some dissection is anticipated, Schleich's method is better, in which the 
needle is plunged directly into the tissues and a sufficient quantity of 



Fig. 5. — Local anesthesia; the 
zone of infiltration is narrow 
when the needle is pushed for- 
ward and emptied rapidly 
(Veau.) 



Fig. 6. — Local anesthesia; the 
zone is broad when the needle is 
introduced slowly. (Veau.) 



the solution discharged to raise a wheal. The needle is then reintro- 
duced alongside the wheal for another injection. The anesthesia may 
be renewed from time to time during the operation. 



LOCAL ANESTHESIA, SCHLEICH'S SOLUTION. 



17 



Schleich's formula is as follows: 



NO. I, STRONG. 




Cocain. Hydrochlor., 
Morphin. Hydrochlor., 
Sodii Chloridi, 
Aq. DestilJat., 


gr. iii. 

gr. |. 
gr. 111. 
§ iii, 3 iiss. 


NO. 2, NORMAL. 




Cocain. Hydrochlor., 
Morphin. Hydrochlor.. 
Sodii Chloridi., 
Aq. Destillat., 


gr. iss. 

gr. |. 
gr. iii. 
§ iiiss. 


NO. 3, WEAK. 




Cocain. Hydrochlor., 
Morphin. Hydrochlor., 
Sodii Chloridi., 
Aq. Destillat., 


gr. f. 
gr. 12- 
gr. iii. 
S iiiss. 



Two or thr,ee drops of a 50 per cent solution of carbolic acid may 
be added to preserve. The solution must be kept cool. Twenty-five 





I 



Fig. 7. — The finger may be anes- 
thetized by a circular injection at its 
base. (Veau.) 



Fig. 8. — Complete anesthesia of 
finger induced by deep injections on 
each side. The upper and lower 
needles represent the primary circular 
injection. (Veau.) 



syringefuls of Number i, fifty syringefuls of Number 2, and 500 of 
Number 3, may be used without danger. 
.The patient should not be permitted to sit up during the anesthesia 



1 8 ANESTHESIA. 

if cocaine is used, for it exposes him to the risk of heart failure. It is 
safer to keep him recumbent for a half hour or so after the operation. 

If a finger or toe is to be amputated, first make an anesthetic ring 
involving the skin only (Fig. 7), and follow this with two deep lateral 
injections to obtund the main nerve trunks (Fig. 8;. 

Spinal anesthesia with stovaine can only very rarely be of use to the 
general practitioner in emergency work, although it is of value under 
certain circumstances. When general anesthesia is contra-indicated 
in operations below the umbilicus, it may be of great service. It is in- 
duced by injecting six to eight drops of a i per cent normal salt solution 
of stovaine into the spinal canal, entering the needle on the right side 
of the spinal column between the fourth and fifth lumbar vertebrae. 

The technique must be carefully studied before attempting the pro- 
cedure. 



CHAPTER IV. 
SUTURES; METHODS, AND MATERIALS. 

Sutures are applied with a view to maintaining the coaptation of 
divided structures. This is necessary to facilitate repair and restore 
function. They serve the additional purpose of checking hemorrhage 
from the smaller vessels. 

Various materials are used, some quite commonly, others rarely 
and for a certain purpose; catgut, silk, silkwormgut, silver wire, kan- 
garoo tendon, and horsehair. The three first named will meet all the 
requirements of the emergency surgeon. 

No material is available which does not have a certain strength and 
which cannot be made aseptic. For emergency work, these materials 
must be already prepared. The creation of a proper suture from the 
raw material is a matter of time and care. 

The general practitioner will do better to buy his sutures put up in 
a form available for immediate use, being first assured that they come 
from a reliable source and are put up in a manner to keep them sterile. 
Much suture material on the market has neither of these qualifications. 

Silk has the advantage of lending itself to emergency sterilization by 
boiling and immersion in an antiseptic solution, nor is it readily con- 
taminated when once sterile. It has the disadvantage of not being 
absorbable. It may be used in buried sutures, but its usefulness in 
that respect grows more and more limited as the art of sterilization and 
preservation of catgut improves.^ It may be used in interrupted 
skin sutures, suture of nerves, of tendons, and of the intestine. 

Catgut is the ideal material for the buried suture. The chromicized 
gut has ample strength and is so prepared as to resist absorption in 
a certain tissue for a certain tim.e. With a little attention to this detail, 
a suture may be selected which will resist absorption until repair is 
complete. Plain catgut can be used in those tissues only which rapidly 
unite. It is ideal for suturing the peritoneum and for ligating vessels 

19 



20 



sutures: methods, and materials. 




Fig. 9. 



-The quilted suture. 
(Moullin. ) 



except the very large ones. It is very easily contaminated. Stewart 
especially recommends the iodized catgut which is prepared by an 
eight days' immersion in iodine and potassium iodide solution. More 
and more catgut is used for suture of the skin. 
^-— y. ^ jm\ Silkwormgut is very strong, non-elastic, non- 

I y^ — ' TM""^ ' — ~° absorbable, readily sterilized, and is much 

V^ > ^ 1 B 1 1 1 employed where the wound is large and deep 

and the tissues tend strongly to spread apart. 
Most surgeons employ it to suture the skin 
and fascia after laparotomy. 

The pagenstecher celluloid linen is in high 
favor with some surgeons; it is more flexible 
than silkwormgut and absorbs moisture with- 
out softening. 

The methods of suturing adapted to emergency surgery are the 
interrupted suture and the continuous suture. Others occasionally em- 
ployed in general surgery are the quilled, 
the quilted (Fig. 9), -the twisted and the 
button sutures. 

The continuous suture is used in 
aseptic wounds only. Therefore, acci- 
dental wounds will only, on rare occasions, 
permit its employment. It has the ad- 
vantage of being very rapidly applied but 
is less sure than the interrupted suture. 
A little practice is essential, for it is not 
altogether easy. Its success depends 
largely upon the assistant. 

This is the mode of making the contin- 
uous suture: Commence by passing the 
suture at the upper ande of the wound, ^ig. 10.— Method of rr.aking a 

^ ^ & continuous suture. Assistant hold- 

Make three successive knots. Two are i^g the suture tight while the 

needle is passed again. (Veau.) 

suificient for catgut. The short thread is 

caught in forceps and retained till the suture is completed, at which 

time it is cut off close to the knot (Fig. 10). 

The needle traverses, successively and obliquely, first the one lip 




THE CONTINUOUS SUTURE. 



21 



of the wound and then the other; each time the assistant seizes the 
thread at the point of emergence, and holds it tightly until the surgeon 
makes a new point of emergence, when the assistant takes a new hold. 
In this manner, the tension of the suture is made absolutely uniform. 
The 7node of arrest of the continuous suture is important. In making 
the terminal knot, the suture must not be allowed to relax. To accom- 
plish this, the surgeon slips the index finger in the last loop instead of 
pulling the thread all the way through, as was done with all the others. 




Fig. II. — Completing the 
continuous suture ; holding 
the suture tight with finger 
through loop while getting 
ready to tie. (Veau.) 



Fig. 12. — Method of ty- 
ing completed continuous 
suture. (Veau.) 



Fig. 13. — Continuous su- 
ture interrupted in its course. 
(Hartmann.) 



Traction with this finger holds the line of suture tight while the ter- 
minal thread on the one side is knotted three times with this loop on the 
other side (Figs. 11, 12). 

If the continuous suture is long, its stability is insured by crossing 
the threads at the middle of the line of suture (Fig. 13). The suture is 
thus interrupted at its middle in this manner: the needle is simply 
passed back under the last loop, at the same time care being taken that 
the suture does not slip. The succeeding steps are the same as before 
(Figs. 14, 15). The suture completed, the loose ends are cut off 
close to the knot. 



sutures; methods, and materials. 




Fig. 14. — Method of 
interrupting the con- 
tinuous suture in its 
course. Needle passed 
back under last loop. 
(Veau.) 



IS.— The 
has been 



Fig. 
needle 
passed through the 
loop which is drawn 
down tight and the 
suture proceeds as 
before. (Veg,u.) 



Fig. 16. — Method of passing deep inter- 
rupted sutures. (Veau.) 





Fig. 17. — Tying interrupted sutures. 
Forceps everting lips of wound to se- 
cure coaptation. (Veau.) 



Fig. 18. — Method of passing 
superficial sutures. (Veau.) 



THE INTERRUPTED SUTURE. 



^Z 



The interrupted suture is generally employed in suturing the skin, 
and may be of silk, silkwormgut, silver, etc. It must not be absorb- 
able. These sutures may be placed deeply or superficially, in the one 
case \vhere there is much tension, in the other for mere approximation. 
The deep sutures are placed two or three centimeters apart. 

The needle is entered one centimeter from the edge and emerges 
the same distance from the other side. The thread is concealed 
through most of its extent (Fig. i6). None is tied until all are 
passed. The lips of the wound are brought together as the knots 
are tied (Fig. 17^. 

A few superficial catgut sutures 
may be necessary if the deep sutures 
do not completely approximate. 
They are passed through the thick- 
ness of the skin alone and very close 
to the edge of the wound (Fig. 18). 

No knot should be drawn too tight. 
It may interrupt the circulation and 
defeat repair. The knot should be 
made to one side of, and not over 
the wound (Fig. 19). 

If all goes well, the sutures may 
he removed toward the eighth day. 
infection. 

Method oj Removing Sutures. — Seize the loop with a dissecting 
forceps held in the left hand. With a pointed scissors divide the 
thread close to the skin, being careful not to cut between the knot 
and the forceps, else one will be trying to pull the knot through the 
skin. 

Suppose, in spite of care, injection occurs. The temperature 
reaches 100^° on the following day. On the second day following, 
it is a little higher. Upon removal of the dressing, the skin around 
the wound is found to be reddened and swollen. Remove two or 
three of the middle sutures at once. Secure drainage and use a wet 
dressing. This will usually check the infective process and pus for- 
mation. 




ffow to da iL 



How not to do H 



Fig. 19. — Sutures must not be tied 
too tight. (Moallin.) 



Remaining too long, they favor 



24 



SUTURES, METHODS, AND MATERIALS. 



The subcuticular suture is of great service in aseptic operative wounds, 
wherever it is especially desired to prevent a scar. It is made in this 
manner: 

Introduce a small needle threaded with cat- 
gut, one-fourth inch above the upper angle of 
the wound, and let it penetrate the skin and 
emerge exactly at the upper angle. It penetrates 
next the face of the skin incision, taking a bite 
first on one side and then on the other exactly 
opposite (Fig. 20). At the end, the needle 
traverses the skin in the same manner as it 
entered at the upper angle and the sutures are 
then tightened (Fig. 21) until the edges of the 
wound are exactly coapted. The ends are 
secured from slipping either by knots or by past- 
ing them down with collodion or adhesive plaster. 
T <r If the thread is not absorbed, it may be removed 

about the sixth day by clipping one end close to 




Fig. 20. 



Fig. 2: 



mJthodfng'if ''piss'ing^and ^^^ ^^^^ ^^^ ^^^^ gently drawing it from the 

tightening. (Veau.) Other end. 

Cannaday (J. A. M. A., Jan. 4, 1908) uses pagenstecher linen and 
after starting the suture secures the loose end by a half bow knot. 
The terminal thread is secured in the same way and slipping or 
loosening is thus prevented. 



CHAPTER V. 
DRAINAGE. 

Drainage may justly be regarded as a matter of antisepsis. It 
prevents sepsis by creating a current which moves away from the wound, 
and by depriving the bacteria of their chief pabulum — the wound exu- 
dates. Drainage facilitates repair by relieving tension. In the same 
manner it relieves pain. But when these points are made the whole 
is said, for drainage is by no means an unmixed good. On the con- 
trary, it is a necessary evil and for these reasons: in reality it is a foreign 
body; it necessitates frequent renewal of dressings; it may injure granu- 
lations; it keeps the wound open and delays healing; in the abdominal 
cavity it sometimes predisposes to fistula, hernia, and intestinal ob- 
struction. Nor is the profession by any means of one mind regarding 
the indications and contra-indications. It is a matter in which one 
cannot be dogmatic. The rule of practice must of necessity vary with 
the patient, the operator, and the environment. 

The emergency surgeon, the general practitioner, will more often 
drain than the hospital surgeon in formal operations. And this leads 
to the fundamental principles involved. 

Aseptic wounds do not require drainage. 

Infected wounds or those suspected should always be drained, for 
infection of any kind demands an outlet. 

Accidental wounds are presumed to be infected, whereas operative 
wounds are presumed to be aseptic. 

As an exception to the rule that aseptic wounds do not require drain- 
age, note that those in which there is of necessity much post-operative 
oozing do better with temporary drainage. Examples: large am- 
putation stumps, and breast amputations. 

Suspected wounds are not drained after the third day if infection 
has not made its appearance nor seems likely to develop. 

25 



26 DRAINAGE. 

Infections are drained as long as there are any discharges. 

The means oj drainage in emergency practice are three; tubes, gauze, 
and open wounds; or combinations of the three. 

Rubber tubes, the larger the better in proportion to the infected cavity, 
are the best means of draining large cavities, and are the sole means 
of draining abscess cavities and large infections. Wherever used they 
must be cut off close to the surface and, in the case of cavities, must be 
anchored by suture or safety pins. 

Gauze. — Plain sterile gauze, which drains by capillarity, is an effi- 
cient means of removing exudates such as serum and blood. It has 
the additional advantage that in appropriate cases it may be at the 
same time employed for hemostasis. It has the disadvantage that it 
soon ceases to drain, acquires adhesions and is painful to remove. 

Tubal and capillary drainage are advantageously combined in the 
"gauze wick" and "cigarette drain." A "gauze wick" drain is made 
by splitting a tube of the required length and fitting it loosely with a 
strip of gauze. When the tube is carried to the bottom of the cavity 
the projecting gauze is brought in contact with the oozing surface, is 
hemostatic, and finally may be removed without disturbing the tube. 
A cigarette drain acts on the same principle and is essentially a series 
of wick drains one within the other. To make a "cigarette drain" 
take a ten inch square of rubber tissue, cover it with four or five 
layers of sterile gauze, and roll the whole into a slender cylinder. 

"Wick" and "cigarette" drains should be removed on the second 
or third day. If infection is present at that time, a tube should be sub- 
stituted; a tube must be employed if infection develops later. Tubes 
employed in the drainage of pus cavities should be removed, cleaned 
and reinserted at least every third day and are to be shortened pari 
passu with granular repair. 

As has been said, an open wound is a means of drainage, and for 
that reason accidental incised wounds are, as a rule, not completely 
sutured. Lacerated wounds not reparable need no other drainage than 
that afforded by the gauze dressings. 

To note briefly some examples of drainage: Abscesses are always 
to be drained with tubes. 

Acute spreading infections are to be drained with tube... 



DRAINAGE. 27 

Accidental incised wounds are to be drained with tubes or simply 
by rubber tissue if the wound is small. 

Operative wounds of the soft parts in emergency practice are often 
best drained superficially — all the layers are completely closed except 
the skin. 

An empyema or purulent peritonitis must be drained with tubes. 

Many thoracic and abdominal conditions are to be drained with the 
wick or cigarette drain. If there is no probability of infection, if 
there is not much oozing, do not drain at all. 

In compound fractures and compound dislocations drain only the 
skin wound. If infection develops, deep drainage must be substituted. 

Further details will be given in connection with the various operations 
requiring drainage. 



CHAPTER VI. 
DRESSINGS, BANDAGES, SPLINTS. 

The emergency surgeon needs no great variety of dressing materials. 
If he has sterile gauze and sterile absorbent cotton he can cjfficiently 
meet all the indications so far as dressings are concerned; for these 
materials furnish in the highest degree the properties which pertain 
to a good dressing. A good dressing is sterile, absorbent, and pro- 
tective. It need be nothing more; it must be that. For emergency 
work it is better to buy these already prepared and ready for instant 
use. But they must come from a reliable source. Even the most 
trustworthy products are not always aseptic. In major operations 
they should be re -sterilized if possible. Of course the surest way to 
sterilize is by steam. Still these materials exposed to the high heat in 
the closed oven of the kitchen stove might reasonably be expected to 
be germ free. Medicated gauze is often useful but not essential, nor 
so much employed as formerly. It may be improvised by dusting 
the plain sterile gauze with the preferred antiseptic powder at the 
time of dressing. For that matter all of the dressing may be impro- 
vised for temporary use from muslin, linen or cheesecloth. Towels 
or sheets may be prepared by boiling for fifteen minutes in soda solu- 
tion, rinsing in cold sterile water, wringing out the water and com- 
pleting the drying process on the stove. From these materials one 
may provide not only dressings but compresses and sponges for the 
operation. An aseptic wound requires that the dressing be dry; 
whatever slight serous oozing there may be is thus rapidly absorbed. 

Septic wounds require a dressing moist with some antiseptic solution. 
For one thing the moist gauze conforms better to the irregularities 
of a lacerated wound. Again the antiseptic agent exerts some slight 
destructive effect, perhaps, upon the germ already in the wound and 
is a more effective screen against those trying to get in. ^loist boracic 
and bichloride gauze are the most commonly used. If acute sepsis is 

28 



BANDAGES. 29 

present, sterile gauze saturated with peroxide of hydrogen is to be 
recommended. 

The dressings must be ample. Too often an aseptic operative wound 
eventually becomes infected merely because not sufficiently protected. 
The dressings must not only be thick enough, but they must extend 
widely beyond the limits of the wound. It is a poor dressing indeed 
if one can lift its edges and inspect the wound. 

The frequency of redressing is variable. In general the fewer dress- 
ings the better. The aseptic operative wound should need but two 
dressings. The original dressing is removed when the sutures are 
taken out on the eighth to the tenth day. 

The septic wound may need to be dressed daily. A wound prob- 
ably infected but not septic, one in which a drainage tube was used, 
will need to be dressed on the second to the fifth day, when the drain- 
age tube is removed. The frequency of dressing thereafter will de- 
pend upon the degree of sepsis. 

It is good practice in the case of any kind of wound to change the 
dressing whenever soiled, for sterile exudates may become good cul- 
ture media. One may, however, follow Senn's suggestion, dusting 
the saturated area with boro-salicylic acid or other antiseptic powder 
and covering with an additional layer of cotton and bandage. 

Pain or rise of temperature after the first twenty-four hours is always 
an indication to change the dressing and inspect the wound. A 
loosened dressing calls for renewal. The dressing that slips or rubs 
is a very poor one. When the dressings are adherent to the wound sur- 
face, they are to be saturated with warm sterile water or wath peroxide 
of hydrogen. The latter is excellent when the dressing contains dried 
blood. When changing the dressings any undue movement of the 
parts must be avoided. The principles of support and functional 
rest are not to be neglected even for the short time the dressing is off. 

BANDAGES. 

The gauze roller is porous, absorbent, protective, and therefore a 
part of the dres^ng. The wound is covered with gauze, the gauze 
is amply covered with absorbent cotton and the whole retained by a 
smooth bandage, uniformly compressive. Bandaging, as the older 



so 



DRESSINGS, BANDAGES, SPLINTS. 



doctors knew it, is almost a lost art, for the gauze roller is accommo- 
dating and adhesive plaster convenient. One may give a dressing the 
appearance of stability without its being in reality efficient. The 
bandage must be so applied that it will not slip and will remain closed 
at either end. It must extend well beyond the limits of the subjacent 
dressing, and in the case of the limbs must reach beyond the next 
joint above. For example: a dressing of the foot must extend above 
the ankle; of the leg, above the knee; of the forearm, above the elbow. 




Fig. 22. — Double spicae of groin. (Heath.) 



In the region of the groin a double spica should be employed, extend- 
ing well up over the abdomen and down over the thighs (Fig. 22). 

A bandage of the neck, that it may not slip, must include the head 
and shoulder. 

The dressings of the abdomen and thorax are best held in place by 
wide bands of flannel firmly applied and secured by safety pins, and 
whose edges are held down by suspenders and perineal strips. 

To apply a bandage to a Hmb, for example: stand in front of the 



METHOD OF APPLYING A BANDAGE. 



patient. Place the free end of the bandage in contact with the dressing 
by its outer surface, and hold the roller to the outside of the limb — 





Fig. 23. — Bandage of foot. (Heath. 



Fig. 



-Bandage of foot. 
(Heath.) 



Heel covered. 



in the right hand for the left limb, in the left hand for the right limb. 
To maintain uniform pressure in spite of the limb's change in contour 
as the bandage progresses, certain modifications of the ordinary spiral 




Fig. 25. — Spica of foot. (Stewart.) 



or circular turns are necessary — the "spiral reverse" and "figurc-of- 
eight" are to be employed. The "spiral reverse" is used where the 



z^ 



DRESSINGS, BANDAGES, SPLINTS. 



circumference rapidly changes, as in approaching the calf of the leg. 
To make the reverse, the bandage is slackened when the outer side of 
the limb is reached and a half rotation is made, by a twist of the wrist. 
The bandage is then continued on around the leg until the outside is 
again reached when the reverse is repeated. The "figure-of-eight" is 
most useful in the region of the joints. 

Bandage for the Foot. — (Fig. 23.) Begin near the toes with spiral 
turns, reversed as the ankle is neared. Encircle the ankle with the 




Fig. 26. 

Bandage of leg. 



Fig. 27. 
(Heath.) 



figure-of-eight turns and continue the spiral turns up the leg. If it 
is desired to cover the heel, the first turn should cross the upper part 
of the heel and over the front of the joint; the second turn overlaps 
the lower half of the first; the third turn overlaps the upper half of the 
first. The roller on the third turn reaches the dorsum of the foot, and 
is carried obliquely across toward the little toe and the foot is covered 
by spiral turns which progress upward, or it may be applied as indi- 



BANDAGE FOR THE KNEE. 



33 



cated in Figure 24. The spica of the foot is indicated by Figure 25. 
If it is desired to cover the toes, back and forth folds extending from 
in front of the ankle to a corresponding point on the sole may be run on 
and held in place by additional circular turns about the foot. 

Bandage for the Leg. — Begin above the ankle with spiral turns, pro- 
gress upward and, as the calf is approached, use the reverse (Fig. 26); 
or a ''figure-of-eight" may be employed throughout (Fig. 27), but the 
latter does not fit so well about the calf as the former. 





Fig. 28. — Figure of "8" of knee. 
(Heath.) 



Fig. 29. — Bandage of knee. 
Spiral reverse. (Heath.) 



Bandage for the Knee. — This may be a continuation of the leg bandage 
or may include the knee alone; in either case it is a figure of eight 
running from below the patella around the outer side of the knee, 
across and up behind the knee to the inner condyle. Now make cir- 
cular turns about the thigh. From the inner condyle cross the knee 
obliquely downward and outward to the head of the fibula; make 
a circular turn about the leg below the knee and when the patellar line 
3 



34 



DRESSINGS, BANDAGES, SPLINTS. 



is reached, begin over again the "figure-of-eight," lapping the preced- 
ing one (Figs. 28, 29). 

Bandage jor the Groin. — Begin at the inner end of the groin and carry 
the roller upward and outward to the iliac crest, around to the opposite 
crest, obliquely across the belly toward the pubes, around the thigh 
to the starting point. Repeat these turns as often as necessary, each 
overlapping the preceding (Fig. 30). 

The Double Spica. — The right groin is bandaged as described above. 




Fig. 30. — Spica of groin. (Heath.) 



When the roller, carried about the body, reaches the left side of the 
pelvis, it leaves the original track, follows the left groin downward and 
thence around the thigh; is then carried across the belly and around 
the body to the right groin again. These bandages may be applied 
with the patient standing or with the pelvis on the Volkman rest. 
For the perineum and pelvis, one may use the "St. Andrew's cross," 
which, after a turn about the body, crosses over the left groin, behind 
the left thigh just below the nates, obliquely upward across the peri- 



BANDAGES FOR THE BREAST. 



35 




Fig. 31. — Bandage or breast. (Heath.) 




Fig. 32. — Bandage for both breasts, (Heath,) 



36 



DRESSINGS, BANDAGES, SPLINTS. 



neum, over the right groin toward the right iliac spine. It then passes 

around the left ihac spine and down the left groin across the perineum. 

Bandage jor the Breast. — Begin with two or three turns about the 





Fig. 33. — Finger bandage. 
(Heath.) 



Fig. 34. 



-Spica of the thumb. 
(Heath.) 



chest, carry the roller across the breast to the sound side; next carry it 
under the affected breast to the opposite shoulder; across the back to 
the breast again and up over the shoulder and then around the body 




Fig. 



-Bandage for all the fingers. (Heath.) 



again (Fig. 31). Both breasts may be bandaged at the same time, 
carrying the turns about first one breast and then the other (Fig. 32). 
Bandage jor the Finger. — Begin with two or three turns about the 



BANDAGE FOR ARM. 



37 



wrist and then carry the bandage across the dorsum of the hand and 
base of finger and run it down to the tip by two or three oblique turns; 
bandage from the tip to the base by regular circular turns. From the 
base, carry the bandage across the dorsum of the hand and around the 
wrist again (Fig. ;^7,). 

Bandage for the Thumb. — Begin at the ulnar side of the wrist and 
carry the bandage across the dorsum around the wrist for a turn or two. 
Next carry the roller obliquely across the dorsum of the hand and to- 




FiG. 36. — Bandage for arm. (Heath.) 



ward the radial side of the thumb, as near the tip as desired. Secure 
by a circular turn and then carry the roller back to, and around, the 
wrist again and so proceed, progressing toward the base of the thumb 
(Fig. 34). Bandage for all the fingers and thumb, see Fig. SS- 

Bandage for the Hand and Arm. — Begin with circular turns around 
the wrist and then carry "figure-of-eight" about the wrist and hand; 
finish with spiral turns progressing up the arm (Fig. 36). 

Spica jor the Shoulder. — Begin on the arm about the insertion of the 



38 



DRESSINGS, BANDAGES, SPLINTS. 



deltoid and make two or three circular turns about the arm. Next 
carry the roller across the shoulder, approaching the sound axilla 
from behind; across under the axilla and over the breast to the injured 
shoulder and around the arm again (Fig. 37). 

Bmidage for the Neck. — The shoulder and head must be included in 
the bandage for the neck if it is to be effective. Begin on the shoulder 
and carry the roller through the axilla and around the neck once or 
twice. Take the next turn about the neck and beneath the jaw, be- 
hind the ear on the sound side, over the top of the head, down in front 
of the ear on the affected side. Next carry the roller horizontally 
around the neck and then beneath the jaw once more; again vertically 




Fig. 37.- 



Spica for shoiilder. 


Fig. 38.- 


—Bandage for 


Fig. 39. — Barton's 


(Heath.) 


head. 


(Stewart.) 


bandage. (Gould's 
lUust. Diet.) 



around the head but this time it passes in front of the ear on the sound 
side and behind the ear on the affected side. Carry the roller now a 
third time beneath the jaw and finally from the occiput round the fore- 
head to fix the other turns. 

Bandage for the Head. — A dressing may be secured in many instances 
by simple turns about the forehead and occiput; but the bandage 
may be made to hold firmer if, as it approaches a certain point, it is 
raised in one turn and lowered in the next. It has the appearance of a 
spiral reverse (Fig. 38). 

Barton's bandage may be used (Fig. 39). Begin at the top of the 
head, carry the roller beneath the chin, up to the vertex, across and to a 



BANDAGE FOR THE HEAD. 



39 




Fig. 40. — Capitellum. (Heath.) 




Fig. 41. — Capitellum completetl. (Heath.) 



40 



DRESSINGS, BANDAGES, SPLINTS. 



point below the occiput. From this point, carry it forward to the chin 
and on to the occiput. Bring it up to the top of the head and again 
beneath the chin and proceed as in the beginning. 

Figures 40 and 41 represent one method of applying the recurrent 
or capitellum to the head. 

The crossed bandage for both eyes is a figure-of-eight with circular 
turns about the head (Fig. 42). 

Bandage for a Stump. Begin w^ith circular spiral turns some dis- 
tance up the limb. Carry the bandage back and forth over the end 
of the stump; and finish by more circular turns. 



SPLINTS. 

Plaster roller bandages are ideal fixation splints in surgery in emer- 
gency work in the treatment of most fractures. They have the dis- 
advantage that they are difficult to remove. For that reason, whenever 
frequent inspection is necessary, splints should be used instead. Plas- 





FiG. 42. — Bandage for both 
eyes. (Heath.) 



Fig. 43- — Method of rolling plaster 
bandage. 



ter-of -Paris bandages are best prepared from crinoline or cheesecloth. 
Pour the plaster on the table or in a shallow receptable; start the loose 
end of the crinoline roller through the plaster, rubbing it in thoroughly, 
and as fast as it is impregnated have an assistant reroll it. These 
bandages must be kept in an air tight container. (Fig. 43.) 

Method of Applying. — When the limb is ready, washed and covered 
with glazed cotton or stockinet, the plaster roller is set in a pan of warm 



PLASTER SPLINTS. 4 I 

water deep enough to cover it. When the bubbles cease to rise, it is 
ready to apply. Seizing it at each end wring it gently. Begin by 
making a few oblique turns, at first to secure the dressing or cotton, and 
then cover the limb by systematic circular turns, progressing from be- 
low upward, each turn overlapping the preceding one. The " reverse " 
must not be used. A little loose plaster may be spread on and moist- 
ened to give a smooth and even finish. The limb must be supported 
and the extension maintained until the plaster has hardened. A little 
salt added to the water hastens the process. 

Plaster splints are made by cutting several thicknesses of crin- 
oline, appropriate to the shape of the limb. It is saturated with plaster, 
each layer separately, dipped in warm water until well soaked, then 
applied and moulded to the limb. Fix it with circular turns of a mus- 
lin bandage. The second splint, if needed, is then applied and fixed 
by a second series of circular turns. The splints may be fixed by a 
plaster roller if desired. 

The Bavarian plaster splint is particularly useful in immobilizing 
the leg. Cut two pieces of flannel long enough to extend from the up- 
per end of the thigh under the heel to the ball of the toes, a few 
inches wider than the greatest girth of the limb. Stitch these pieces 
together along the middle line for the length of the leg. Put the 
splint thus formed under the limb, with the seam exactly in the mid- 
dle; bring the inner half around, fitting it to the leg, the dorsum and 
sole of the foot, like a stocking. Smear this stocking with liquid plaster 
and, before it sets, turn the outer half over the plaster and mold it and 
adjust the end pieces to the sole. The splint can be easily removed, as 
the seam along the back acts as a perfect hinge. 



CHAPTER VII. 
SHOCK. 

Shock is a constitutional state characterized by lowered blood pres- 
sure, due to vaso-motor paralysis. 

Peripheral impulses traveling along the afferent nerves reach the 
spinal cord and overv^helm those centers which regulate the blood 
pressure. 

In practice, the term "shock" includes the complex of symptoms 
arising from vaso-motor paralysis, hemorrhage^ mechanical interfer- 
ences with circulation and respiration, and beginning infection. 

It may not be possible to analyze the symptoms, determining the part 
played by each of these various conditions, nor is it necessary to do so. 

Nevertheless, the proper understanding of shock as a separate entity, 
is essential in emergency surgery next to skill in hemostasis. 

Lucy Waite (Medical Record, Sept. 8, 1906), after reviewing the 
subject from every standpoint, concludes that according to our present 
light we must consider it primarily a disturbance of the great sympa- 
thetic nervous system; secondarily, the vascular system, resulting in 
vaso-motor paresis and dilatation of the right side of the heart and the 
large vessels; in natural sequence there follows derangement of the 
solar plexus and the automatic visceral ganglia; finally there is sup- 
pression of visceral activity — of rhythm, absorption, and secretion. 

The symptoms of shock vary in degree with its severity and are 
chiefly incident to the lowered blood pressure: thirst, pallor, subnor- 
mal temperature, shallow breathing, frequent sighing or yawning, 
rapid pulse, relaxed sphincters, faintness, nausea or vomiting, and 
unconsciousness. 

These may appear in their slightest manifestations or in such forms 
as usher in death. As Waite says, syncope causing always a cerebral 
anemia is practically identical with the last manifestations of over- 
whelming shock. 

42 



DIAGNOSIS OF SHOCK. 43 

Whether shock will be mild, severe, or fatal depends upon the state 
of the individual, the character and continuance of trauma, the means 
of injury and the tissues wounded. Age, sex, general health and 
mental state are factors to be taken into consideration. 

Crushing injuries with mangled nerves sending their constant sig- 
nals to the exhausted vaso-motor centers furnish conditions favorable 
to fatal shock. Railroad accidents as a means of injury are typical of 
such as produce the severest symptoms of shock, for fright and violent 
emotions even without injury may be followed by vaso-motor paralysis. 

Certain tissues resent insult more than others. Those which line 
the body cavities are most sensitive with respect to injury; the perito- 
neum, the pleura, the dura and the synovial membranes of the large 
joints. This is true whether the trauma be accidental or operative. 

The diagnosis of shock as distinct from hemorrhage and collapse can- 
not always be made with certainty. As Waite says, the diagnosis of 
shock is simply the recognition of the clinical phenomena, for we have 
no chemical or pathological findings to aid us. 

In many instances it may be differentiated from collapse by the 
history of the case. 

In collapse the heart action is slow and feeble, whereas in shock it 
is rapid and feeble. 

In hemorrhage the symptoms may be rapidly progressive, but in 
uncomplicated shock the symptoms are stationary or improve. Ob- 
serve, therefore, the action of the pulse and the movement of the tem- 
perature. In hemorrhage the temperature falls and the pulse rate in- 
creases. In shock the pulse becomes gradually slower; the tempera- 
ture gradually rises. 

The prognosis in the severe cases will be for a little time decidedly 
uncertain. Any increase, not too long delayed, in the blood pressure 
and the attendant improvement is a cause for hope. It may take 
many hours before the reaction is complete. 

Any aggravation of the symptoms after reaction is once under 
way never indicates a return of the shock, but points to hemorrhage 
or infection. 

The treatment of shock has been the subject of much discussion in 
recent years. The most diverse opinions exist and the most diverse 



44 SHOCK. 

methods have been proposed, but we have learned from the experience 
of Crile and others that it is as important to know what not to do as 
what to do. 

The whole list of cardiac and spinal stimulants so commonly in- 
jected hastily, indiscriminately and collectively, are shown to be not 
only useless but distinctly harmful. The patient doubtless often 
recovers not on account of, but in spite of, such treatment. 

These directions are sufficient to be borne in mind: disturb the 
patient as little as possible; lower the head; keep the body warm; 
attempt no operative measures until the symptoms are improved, 
unless it be to check hemorrhage, or to amputate in certain crush- 
ing injuries. 

Adrenalin chloride is the most generally useful remedy to raise 
blood pressure in shock pure and simple, and given hypodermatically 
or intravenously, it very seldom completely fails. 

Crile was enabled by means of intravenous infusion of adrenalin 
and salt solution, combined with artificial respiration and thoracic pres- 
sure, to arouse a human heart after it had ceased to beat for nine min- 
utes, and its action was thus sustained for one-half hour. 

It must be given in small doses, frequently repeated. The effects 
are powerful but fleeting. 

Hypodermatically, give 5 to 15 minims of the i-iooo adrenalin 
solution and repeat every 20 or 30 minutes. 

Intravenous infusion is even more satisfactory and certain. Give 
continuous infusion of adrenalin salt solution until there are signs of 
reaction. One teaspoonful of i-iooo adrenalin added to one quart 
of normal salt solution is of sufficient strength. 

Normal salt solution alone is effective within certain limits but finds 
its greatest field of usefulness in shock coexistent with hemorrhage. 
In shock uncomplicated by extensive loss of blood, the saline solution 
must be used sparingly, perhaps better by enema or hypodermoclysis ; 
used in large quantities intravenously it may eventually defeat the end 
for which it is employed by acting as a mechanical obstruction to 
respiration. 

For it must be remembered that under such circumstances it finds 
its way into the thoracic and abdominal tissues and interferes with the 



PREVENTION OF SHOCK. 45 

movements of the diaphragm and ribs by its mere presence. Accord- 
ing to Crile, 32c c.c. per kiJo of body weight led to such accumulation 
of fluid in the splanchnic area as to embarrass respiration. 

Do not give, then, more than two or three pints of normal salt solu- 
tion injected slowly, in uncomplicated shock. (For technique of in- 
travenous infusion see page 48.) 

Crile's pneumatic suit seems to be entirely trustworthy as a means 
of raising blood pressure, but, of course, cannot be used in the shock 
occurring in emergency practice. 

The prevention of shock is always something to be considered in 
operative work. Morphia, J grain hypodermically, before the anes- 
thesia, is a real aid. " Blocking" the nerves by cocaine injections above 
the site of operation is likewise advantageous and is recommended 
by Gushing and Crile. The nerve may be exposed in its course under 
local anesthesia and in turn injected. 

In abdominal work the viscera must be handled with care, for, as 
Byron Robinson has showm, shock from this source is directly propor- 
tionate to the amount of manipulation or traction upon the viscera. 



CHAPTER VIII. 
HEMORRHAGE. 

DEFINITIONS. 

1. Arterial hemorrhage is due to wounds of arteries and is char- 
acterized by spurting and the bright red color. 

2. Venous hemorrhage is due to wounds of the veins and is char- 
acterized by dark color and steady flow. 

3. Capillary hemorrhage is characterized by persistent oozing and 
spontaneous arrest. 

4. Parenchymatous hemorrhage is due to wounds of those organs 
and tissues in which the small arteries terminate directly in veins, no 
capillaries intervening, as in the erectile tissues. 

5. Primary hemorrhage occurs immediately after the injury. 

6. Intermediate or reactionary hemorrhage occurs within twenty- 
four hours and is due to the release of clots or the slipping of the liga- 
ture. 

7. Secondary hemorrhage occurs after twenty-four hours, before the 
cicatrization of the wound, and is usually due to sloughing or suppur- 
ation or the too rapid absorption of the catgut ligature. 

8. Internal or Concealed Hemorrhage is obtained when the blood is 
emptied into one of the large cavities; abdomen, thorax or cranium 

CONSTITUTIONAL EFFECTS OF HEMORRHAGE. 

The constitutional effects of hemorrhage vary with the amount and 
the rapidity of the loss of blood. Thus a comparatively small amount 
of blood poured out rapidly will produce more marked symptoms 
than a much larger amount drained away slowly. 

The constant accompaniments of severe hemorrhage are pallor, 
dizziness and faintness, rapid and weak pulse, subnormal temperature, 

46 



DIAGNOSIS OF HEMORRHAGE. 47 

rapid and irregular breathing, frequent yawning or sighing, nausea 
and vomiting. 

Fatal hemorrhage, or one likely to be so, is indicated by livid lips, 
blue finger nails, dilated nostrils, pallid mucous membranes, dyspnea, 
ringing in the ears, syncope, collapse and unconsciousness. 

Subsequent to the arrest of a dangerous hemorrhage occur rapid and 
irregular pulse, rise of temperature, asthenia, a disturbed mental con- 
dition, usually muttering delirium. This is hemorrhagic fever. As 
the general condition improves, the mind gradually clears up. The 
lowered vitality following the hemorrhage favors the development of 
various inflammatory processes and one must carefully watch for the 
onset of these. 

The diagnosis oj hemorrhage is not difficult except in the case of 
internal hemorrhage or when shock is present. 

In the case of bleeding into the cranial cavity, various forms of 
paralysis and nervous disturbances, together with the general symp- 
toms, will form the basis of the diagnosis. 

In the case of bleeding into the thorax and abdomen, the symptoms, 
the physical signs, and the history of the case will point to the con- 
dition. (See Injuries to Thorax and Abdomen.) 

When shock is also present it may be almost impossible to tell 
how much of the symptoms are due to the one or the other, for the 
symptoms of shock and hemorrhage are practically identical. 

It is useful to remember that the symptoms produced by shock are 
usually immediate and tend to improve, except in the fatal cases. 
On the other hand, the symptoms of unchecked hemorrhage tend to 
grow worse. 

TREATMENT OF HEMORRHAGE. 

The First Indication is the Arrest oj Hemorrhage. Constitutional 
measures are then applied with a view to supporting the heart's action. 
In moderately severe cases give one-half ounce of whiskey or a hypo- 
dermic of strychnia {^^ to ^V g^-)j or of adrenalin chloride, and repeat 
every hour until the symptoms have improved. Apply warm blankets, 
hot water bottles or hot irons well wrapped. Do not burn the patient. 
Keep him quiet, with head bwered. Attend to the ventilation. As 



48 HEMORRHAGE. 

soon as possible give warm drinks and a nutritious but easily digested 
diet. Do not overstimulate, as the reaction in that case will be unduly 
severe. 

In the dangerous cases of hemorrhage in addition to these measures, 
do not fail to employ normal salt solution either by enema, subcu- 
taneous injection or intravenous infusion. 

In the gravest cases, enemas will be of no avail for absor])tion has 
practically ceased. 

Hypodermoclysis will be a little better. For this purpose employ: 

I^ — Sodii chloridi., 5 i- 

Sodii bicarb., Gr. xv. 

Aq. destill., S xvi. 

The necessary apparatus: is a carefully disinfected fountain syr- 
inge or a funnel with rubber tubing, a large needle (an aspirating 
needle). One-half ( \ pint or more of the solution is injected by this 
means under the skin over the abdomen or breasts. 

Intravenous Infusion. In the gravest cases the same solution by 
the same means may be injected into the venous circulation. Select a 
vein at the elbow^ employ the strictest asepsis and expose the vein by 
incision. Loosen it from adjacent tissues by careful blunt dissection 
and slip three catgut ligatures under it. Introduce the needle, or the 
vein may be opened and a canula used. The canula or needle is to 
be held in place by the middle ligature. Slowly inject a pint or more 
of the solution, the temperature of which should be 105 to 115. With- 
draw the canula, remove the middle ligature and tie the two remaining. 
Close the wound and dress aseptically. Keep the funnel full during 
the injection so that no air may be carried into the vein. 

Crile recommends direct transfusion from the vein of a well person 
into that of the patient, but of course this method is scarcely available 
in emergencies of general practice. 

Parke-Davis & Company markets a sterile salt in sterile tubes 
which needs only to be emptied into a liter of sterile water to form a 
solution for instant use. The formula used is as follows: 

Calcium chloride, 0.25 gm. 

Potassium chloride, . o.i gm. 

Sodium chloride . 9.0 gm. 



ARREST OF HEMORRHAGE. 49 

Remember that intravenous infusion is not to be employed until 
the hemorrhaore is arrested. 



HEMOSTASIS— ARREST OF HEMORRHAGE; GENERAL 
PRINCIPLES. 

Spontaneous arrest of hemorrhage occurs under several circumstances. 
Contraction and retraction of the injured vessels, diminishing blood 
pressure due to weakening heart action, formation of a clot; these are 
the agents which nature employs. 

Capillary hemorrhage tends to spontaneous arrest, likewise the 
arterial hemorrhage of lacerated w^ounds. 

Hemostatic fneasures locally applied are chemical, thermal and 
mechanical. 

(A) Chemical remedies, chiefly styptics, are now very rarely em- 
ployed. Such as are used, are expected to favor the formation of 
a clot without doing violence to the tissues. In a persistent capillary 
hemorrhage dioxide of hydrogen or acetanilid are often useful and 
harmless, but the most useful remedy locally applied is adrenalin 
chloride. 

(B) Thermal hemostasis is that induced by heat; Cold may be 
used but is much more likely to lower cellular vitality. Hot water 
or hot normal salt solution alone will usually arrest a moderate 
bleeding. Use the solution as hot as can be borne by the hand. Hot 
solutions are especially useful since they serve the double purpose of 
antisepsis and hemostasis. The actual cautery may be necessary in 
spongy tissue where the oozing is persistent but ill defined. The 
iron should not be hotter than a dull red and must be held in contact 
for some moments. 

(C) Mechanical hemostasis includes (i) direct pressure, (2) com- 
pression, (3) acupressure, (4) forcipressure, (5) torsion, (6) ligation. 

(i) Direct pressure is of large service especially in ''first aid" 
treatment. The finger or thumb is pressed directly into the wound 
or on each edge of the wound. If the pressure is to be prolonged, the 
finger will tire and a plug or tamponade of gauze must be substituted. 
Gauze wrung out of a sterile solution is packed into the wound. 

i ' 



50 HEMORRHAGE. 

Direct pressure is sufi&cient in the slight hemorrhage of operative 
wounds. The assistant presses a gauze compress on the bleeding 
surface, withdraws it by a gliding movement and the bleeding prac- 
tically ceases. 

In general, the larger the vessels, the firmer and more prolonged 
must be the pressure. 

In severe hemorrhage direct pressure is, of course, a mere temporary 
expedient. 

Parenchymatous bleeding is checked by direct pressure. The 
wound of the organ is lined with a layer of gauze. In this gauze cavity, 
complete the tamponade. This compress should be withdrawn \^'ithin 
twenty-four to forty-eight hours. It may be painful to pull out. 
Release a little at a time, or soften the adhesions with peroxide. 

2. Compression aims to occlude the vessel above and below the 
wound. In emergency the finger is applied to the artery at some 
convenient point along its course at a distance above the wound. 
Large veins are similarly compressed below the wound. 

Wounds, of the main vessels of the extremities including both the 
vein and artery or either alone may be compressed by the tourniquet. 
The pressure is made firmest over the vessel by laying over its course 
a body such as a small roller bandage, before the constricting band 
is applied above the wound. 

The simplest and most convenient tourniquet is a rubber band or 
tube. After being tightened, the crossed ends are caught and held 
in place by an artery forceps. It must always be remembered that 
the tourniquet is likely to cut off all the blood supply to the extremity 
and if too long applied will produce gangrene. Paralysis may follow 
from pressure on the nerves. Wrap the arm with towel and apply 
the tourniquet over that. 

Capillary oozing is frequently troublesome after the constriction is 
removed. Constriction is objectionable on that account. 

3. Acupressure is now seldom used and yet under certain circum- 
stances may render great aid. The artery may be deep and retracted 
or imbedded in scar tissue or aponeurosis and cannot be seized by 
the forceps. In such a case a needle passed under the artery and 
secured with a figure-of-eight ligature wound around its protruding 



ARREST OF HEMORRHAGE. 



51 



ends will press the artery between it and the tissues and stop the flow 
(Fig. 44). 

4. Forcipressure, the control of hemorrhage by seizing the ends 
of the bleeding vessels with forceps, is the expedient most commonly 
employed in operative wounds. In the accidental wounds of large 
arteries, it affords immediate control of the hemorrhage. For the 
small vessels such pressure is sufficient, the forceps remaining attached 
for a certain length of time. The end of the vessel should be seized 
with as little other tissue as possible. If it is a large vessel it may be 
cleared by a moment's dissection. 

5. Torsion is added to forcipressure if that is not sufficient (Fig. 
45). Before removing the forceps^ it is given two or three turns on 
its long axis. The inner coats of the artery are ruptured and con- 




FiG. 44. — Acupressure. (Moullin.) 



tracted, producing the same conditions favorable to hemostasis as are 
found in the artery in lacerated wounds. If the artery is a little larger 
it is drawn for one-half inch out of its sheath, a second grasps it higher 
up and is held stationary while the lower one twists the intervening 
segment, the purpose being to avoid injury to the sheath and the vaso- 
vasorum. 

In making torsion, do not pull at the same time for fear of tearing 
the other tissues instead of twisting the artery. Torsion must not be 
used where the tissues are loose or cellular. 

Torsion is of advantage especially in plastic surgery for it leaves no 
ligature behind to interfere with repair; but it is not so certain as 
ligation. 



52 



HEMORRHAGE. 



6. Ligation is finally necessary in bleeding from the larger vessels. 
Employ catgut, chromicized or plain, and occasionally silk. 

Lift the attached forceps so as to create a pedicle around which 
pass the thread and tie the first knot (Fig. 46). 

In tying the second knot, two things are kept in mind; to tie tight 
enough that the thread will hold when the forceps is removed, and 
not to include the tip of the forceps in the ligature. The forceps is 
usually removed as soon as the first knot is tied so that one may be 
assured the suture is not badly placed before completing the knots. 
The first knot is secured by a second if silk is used, and by a third if 





Fig. 45- — Torsion. (Veau.) 



Fig. 46. — Showing method of 
tightening the Hgature. (Veau.) 



catgut is used. The threads are then cut short, silk i mm. and 
catgut 2 or 3 mm. Catgut is the preferable ligature and a No. 2 
is amply strong for an artery the size of the radial. 

Ligation en masse may be employed in parenchymatous hemorrhage, 
capillary oozing or bleeding from a deep wound. A catgut suture is 
carried around the bleeding area by a well curved needle and all the 
tissues so included are tied; or, in the case of parenchymatous bleeding 
from a surface, a catgut suture may be carried around the area and 
subsequently tightened after the manner of the purse string. 

HEMOSTASIS IN SPECIAL FORMS OF HEMORRHAGE. 

(a) Capillary — pressure, hot water, ice, adrenalin, peroxide, acetani- 
lid, alum, ligation en masse. 



FIRST AID IN HEMORRHAGE. 53 

(b) Venous — pressure, compression, forcipressure, ligation, removal 
of all obstruction to venous flow above the wound. 

(c) Arterial — ^pressure, compression, forcipressure, torsion, ligation. 

(d) Parenchymatous — pressure (tamponade), heat, ligation en 
masse. 

(e) Intermediate hemorrhage — reopen the wound, turn out the clots 
and treat hemorrhage as if it were a primary one. 

(f) Secondary hemorrhage — reopen the wound, turn out clots and 
apply compresses. If possible catch the ends of the bleeding vessels. 
If the hemorrhage is alarming and it is impossible to control it by 
compresses or forcipressure, apply the tourniquet, in the case of an 
extremity, and ligate the artery in its continuity above the wound. 
If this fails and the artery cannot be tied higher up, amputate. 

FIRST AID IN DANGEROUS HEMORRHAGE. 

It is rare that the regulated measures for hemostasis can be applied 
first hand in a dangerous hemorrhage. There are certain temporary 
and makeshift but extremely useful procedures which the surgeon should 
keep in mind, if for no other reason than that he may give precise and 
definite instruction to the layman who may have to play the part of 
surgeon for the time being. 

Intelligent first aid is the chief factor in saving life in most cases 
of dangerous hemorrhage both in military and civil practice. "Who- 
ever has to meet these emergencies must keep cool. He must re- 
member how to apply three principles of treatment, position, direct 
pressure, compression. 

1. Position. — In case the upper extremity is wounded: hold the arm 
above the head. If it is the lower extremity: put the patient on his 
back and elevate the limb. If it is the face or scalp: place the 
patient in a sitting position. 

2. Direct Pressure. — The wound is small, the bleeding is dangerous: 
plug the wound directly with the thumb or finger or press firmly on 
each edge of the wound; or in any case and better still, if supplied 
with a first aid packet, stuft" the wound tightly with gauze and bandage 
firmly. It should be emphasized that a finger must never be thrust 



54 HEMORRHAGE. 

into a wound except in cases of greatest urgency and where other means 
less likely to cause sepsis are not at hand. 

3. Compression. — The bleeding vessel is recognized and its course 
is familiar: compress it with the fingers at some convenient point or, 
in the case of the extremities, by constricting the limb. 

In lieu of the tourniquet, knot a handkerchief, apply the knot over 
the artery and tie the handkerchief tightly around the limb. If it is 
not tight enough, a stick may be slipped under the handkerchief and 
given a few turns, end for end. A suspender, a rope, or a wire may, 
if necessary, be similarly employed. It must be remembered that, 
on the whole, circular constriction is not without its dangers, and it 
must not be recommended without reserve to the layman. 

The principal arteries near the surface have each certain points where 
compression is most effective. 

The temporal and occipital furnish most of the dangerous bleeding 
in scalp wounds. 

The temporal may be compressed just in front of the upper part 
of the ear. 

The occipital may be compressed in its course from the tip of the 
mastoid upward toward the occipital protuberance. 

The entire blood supply of the scalp may be shut off temporarily 
by a bandage encircling the head, passing from the forehead, above 
the ear, to the base of the skull and thence upward just above the other 
ear to the forehead again. 

The jacial is compressible as it crosses the body of the jaw just in 
front of the masseter muscle. 

The coronary arteries, supplying the lips, are compressed by seizing 
the lip between the forefinger and thumb. 

The carotids are controlled by compression of the common carotid 
over the transverse process of the sixth cervical vertebra. 

Wounds of the vessels of the neck, however, are of such extreme 
danger, including, as a rule, both arteries and veins, that they should 
be controlled by direct pressure in the wound. Nothing can be so 
well trusted here as the finger. 

The subclavian is compressible against the first rib. behind the 
middle of the clavicle. The shoulder is slightly raised to relax the 



COMPRESSION OF PRINCIPAL ARTERIES. 



55 



cendcal fascia and the finger or a padded stick pushed directly down 
upon the artery behind the clavicle. The circulation of the entire 
upper extremity is thus controlled. 

The brachial is compressible against the middle of the humerus or 
the tourniquet may be applied over any part of the artery (Fig. 47). 

The radial and ulnar are not compressible except just above the 
wrist and, therefore, bleeding from them must be controlled by direct 
pressure in the w^ound or by the tourniquet, or by compression of the 
brachial. 





Fig. 47. — Compression of brachial. 
(Moullin.) 



Fig. 48. — Compression of femoral. 
(Moullin.) 



* The palmar arches are not directly compressible but hemorrhage 
from the palm is controlled by grasping firmly a round body as a 
billiard ball, an apple, a stone, and bandaging the hand in this position. 
If this is not practical, the tourniquet may be applied to the forearm 
or the brachial compressed. 

The digital arteries are always easily controlled by constriction 
of the finger above the wound. 




56 HEMORRHAGE. 

The femoral artery is compressible in the middle of the groin against 
the ramus of the pubes but great pressure is required here to control 
its flow (Fig 48). It may likewise be compressed lower down against 
the shaft of the femur. The tourniquet is in this instance the safer 
temporary hemostatic, a compress of some sort intervening between it 
and the artery. 

The popliteal is not compressible. Bleeding must be controlled 
by direct pressure or by compression of the femoral. 

The tibials likewise. They may also be 
controlled by flexing the knee forcibly upon a 
pad, holding the pad in place by a cross piece 
pressing forcibly against the popliteal space 
and in turn held in place by a bandage 

P~ ^^^^Wi around the flexed leg. 
ffl\^^^ The dorsal and plantar arteries can best be 

f controlled by direct pressure or by compressing 

the tibials and peroneal as they cross the ankle. 
infercostlilrtiy.^SriL^A^ The artcrics of the surface of the trunk 
artery, , gauze. a s am. j^^g^ likely to producc daugcrous hemorrhage 
are the internal mammary, the intercostals, and the deep epigastric. 
These can be controlled temporarily only by direct pressure, either 
with the finger or gauze packing. The method of compressing the 
intercostal is represented in Fig. 49. 

EPISTAXIS. 

Epistaxis is a form of hemorrhage often troublesome and requiring 
special treatment. It may occur in one or both nostrils. The 
simpler cases are relieved by the erect position, holding the arms above 
the head, by the reflex effects of cold to the back of the neck, or by 
pressure over the root or sides of the nose. 

If these measures fail the nostril may be syringed with certain 
solutions: hot water; antipyrin, 5 to 10 per cent, which is especially 
recommended in the Am. Text Book of Surgery; adrenalin i to 1000. 

The patient must not blow his nose as this eliminates the clot. 
In the more severe cases try tamponing the anterior nares. If a nasal 



TREATMENT OF EPISTOXIS. 



57 



speculum and a good mirror light are available the anterior nares may 
be systematically plugged through the speculum, or, by such means, 
the bleeding point may be discovered and touched with the point of 
the cautery, with silver nitrate, or wath chromic acid. 

The International Journal of Surgery gives this practical suggestion : 
a layer of cotton is wound around a pen holder until the desired 
thickness is obtained and then withdrawn. The cotton cylinder is 
then moistened, squeezed dry and inserted into the nasal cavity. If 
the projecting end is now moistened it will swell up and thus produce 
sufficient compression. 




Fig. 50. — Tamponing posterior nares. (Stewart.) 



If these various measures fail, then the posteriornares must be plugged. 
For this purpose, in emergencies, an ordinary soft rubber catheter 
is available, in lieu of the Bellocq canula (Fig. 50). It is threaded and 
passed directly backward through the inferior meatus until its point 
emerges below the soft palate. The thread is caught with forceps, 
drawn out through the mouth and held while the catheter is with- 
drawn. One end of the thread projects from the nostril and the other 
from the mouth and a pledget of cotton is tied to this latter end and 
traction made on the other by which means the tampon, guided by 



58 HEMORRHAGE. 

the index finger, is drawn up behind the soft palate and into the 
posterior nares. When the tampon is tied on it, it is a good plan to 
leave the thread still long enough to hang out of the mouth, which will 
greatly facilitate the removal of the plug; otherwise forceps are required 
or else the tampon will have to be pushed backward into the pharynx. 
Any plug put into the anterior nares must be secured by a silk thread, 
lest becoming dislodged, it may drop into the larynx. The plugs 
must not be left in for more than two days. 



CHAPTER IX. 
WOUNDS. GENERAL PRINCIPLES. 

DEFINITIONS. 

A wound is the solution of the continuity of the soft tissues, due 
to trauma. 

(a) Subcutaneous wounds are traumatic lesions of the deeper tissues 
without any definite break in the skin. 

(b) Open wounds are those accompanied by a solution of con- 
tinuity of the integuments. 

1. Incised wounds are open wounds produced by sharp or edged 
instruments. 

2. Stab wounds are those produced by sharp-pointed instruments. 

3. Punctured wounds are those produced by blunt-pointed instru- 
ments. 

4. Lacerated wounds are those produced by tearing or crushing. 

5. Gunshot wounds are those produced by projectiles; shot, bullets, 
cannon balls. 

A penetrating wound is one in which the vulnerating instrument 
reaches a body cavity. 

A perforating wound is one in which the vulnerating body passes 
through the cavity. 

An aseptic wound is one in which there is an absence of the germs 
of inflammation. 

A septic or injected wound is one in which the germs of inflammation 
are present. 

A poisoned wound is one in which some agent destructive to tissue 
is present. 

An operative wound is one produced by the surgeon's knife, and is 
presumed to be aseptic. 

59 



6o WOUNDS. GENERAL PRINCIPLES. 

SYMPTOMS AND CHARACTERISTICS OF WOUNDS. 

All wounds produce more or less pain, hemorrhage, and loss of 
function; in addition, the severer wounds produce constitutional 
disturbances, such as shock, although shock may also occur in slight 
wounds. Hemorrhage depends upon the number and size of the 
blood vessels involved; pain, upon the character of the tissue and the 
extent of nerve injury; loss of function, upon the amount and kind 
of tissue destroyed; shock, upon the mode of injury and the tissues 
concerned. 

Subcutaneous wounds vary widely in the amount of tissue divided. 
There may be any degree, from a mere strain of a few fibers, with 
slight intercellular exudation (bruises), to total division or widespread 
laceration of the various layers of subcutaneous tissue. 

The pain is dull and aching. The hemorrhage is usually slight but 
occasionally may be dangerous. If the hemorrhage is slight, it pro- 
duces merely subcutaneous discoloration, most marked in lax tissues; 
if moderate, it produces an ecchymosis; if serious, a hematoma. 

Contusion of the nerves may produce paralysis, usually temporary; 
or the nerve may be completely divided in subcutaneous wounds, 
and the paralysis be permanent. Shock is nearly always present in 
some degree. 

Treatment. — Subcutaneous wounds are nearly always aseptic, and 
an effort should be made to keep them so. 

The first principle of treatment, is junctional rest. It may be secured 
in bed, or by the use of splints, slings, or bandages. Mere voluntary 
immobilization is not often sufficient. Apply a cotton compress and 
bandage; a flannel bandage firmly laid on, alone, often gives great 
relief. Evaporating lotions, in the case of superficial contusions, 
often do good. Tincture of arnica and witch hazel are common 
domestic remedies. 

The following solution, freely and immediately applied, will often 
prevent a "blacked" eye. 

I^ — x\mmoni. chloridi., gr. v. 

Alcohol, § i. 

Cold, while often giving relief, must be used with caution, since a 



INCISED WOUNDS. 



Ol 



too long application will lower the vitality of the tissues and interfere 
with repair, or will even precipitate death of the injured tissues. 

Heat, in the form of a hot water bottle or hot flannels, is better. 

If the extravasations of blood are moderate, they may be left alone; 
or if persistent and interfering with repair, they may be aspirated. 
In either event, after the inflammatory symptoms have subsided, 
massage is useful to hasten absorption, promote nutrition, and insure 
repair and restoration of function. 

In those cases of severe injury, where the subcutaneous hemorrhage 
is marked and continuous, and where a 
hematoma forms, the skin iiust be incised 
without delay, the clots turned out, the 
wounded vessels secured, and the wound 
subsequently treated as an open one. 

Incised wounds are characterized by sharp 
and severe pain, free bleeding, and a tendency 
to gape. 

The slight actual destruction of tissue, the 
comparative cleanliness of a cutting instru- 
ment, the free bleeding and the gaping pres- 
ent conditions most favorable for transform- 
ing an infected wound into an aseptic one, 
or at least practically so. At any rate, many 
presumably infected incised wounds heal 
with the same readiness and absence of 
inflammatory symptoms as aseptic operative 
wounds. 

Treatment. — For the arrest of hemorrhage, ordinarily, a compress 
wrung out of hot water or normal salt solution is sufficient. If 
this does not have the desired result, the bleeding vessels are to be 
seized with artery forceps and ligated. The hemostasis must be 
complete. 

The wound is next carefully cleansed of clots and foreign bodies, 
using normal salt solution, sterile water, or very weak antiseptic 
solutions. Under favorable circumstances, that is to say if there is a 
reasonable certainty that the wound has been rendered practically 




Fig. 

fected incised wound of thigh. 
(Veau.) 



62 



WOUNDS. GENERAL PRINCIPLES. 



sterile, it is closed. If sepsis is feared, a small tube or capillary 
drain must be employed. (Fig. 51). 

In the first instance, the wound is as carefully closed by suture as 
an operative one. In the second case, sutures are employed, but 
are placed further apart, leaving the wound free of access for cleansing 
solutions and for the free escape of the exudates. If drainage is 
employed, it may usually be dispensed with after the third day if no 
sepsis arises. 

It is safer to regard all large incised wounds as infected. If the 
wound is closed, it must be carefully watched for signs of infection, 
and, on their appearance, be reopened without delay; or the sutures 
may be placed and left untied until the probabilities of infection have 




Fig. 52. — Method of making an incision. (Veau). 



been determined. A wound sealed on the surface and infected below 
is a calamity. 

After repair of the aseptic incised wound, a dressing of plain sterile 
or borated gauze is applied, and over this absorbent cotton and 
bandage. 

In certain instances, as with incised wounds of the face, the dressing 
may be dispensed with, the slight serous exudate being allowed to dry 
and form a crust, which protection is quite adequate. 

Operative wounds are incised wounds, and the aim is always to 
make and maintain them aseptic. Aside from preliminary steriHz- 
ations, there is a proper method of making these wounds, which is 
essential in keeping them aseptic and promoting repair. 



OPERATIVE WOUNDS. 63 

The aim should be to do as little violence as possible to any tissues 
incised. The cutting instrument must be sharp, and the tissues 
evenly and smoothly divided. 

To make a good incision, fix and slightly stretch the tissues on either 
side of the proposed line of section, with the left thumb and index 
finger. Never put the skin on the stretch on one side only. The 
first stroke of the scalpel should divide the skin for the whole length 




Fig. 53. — A good incision. (Veau.) 

previously determined (Fig. 52). Determine before hand, the length 
of incision required. The inexperienced operator is inclined to make 
the wound too short. It may be subsequently lengthened. When the 
skin and subcutaneous connective tissue are divided, identify the deep 
fascia before incising it: it is an important land-mark in nearly every 
part of the body. All the layers must be cut without any gashing or 
notching. The incision in the deeper layers should not be quite so 




Fig. 54. — A bad incision. (Veau.) 

long as in the superficial layer. The good incision gives an equally 
good view of all parts of the cavity (Fig. 53). The bad incision 
creates irregularities which interfere with inspection, not to speak of 
repair (Fig. 54). 

Stab wounds differ from incised wounds only in their greater 
uncertainties. Their narrowness and depth make it ditficult to 
determine what organs and tissues have been involved. 



64 WOUNDS. GENERAL PRINCIPLES. 

In order to make sure a doubtful diagnosis, to repair an injured 
structure, to control hemorrhage, and to insure antisepsis, it is often 
necessary to enlarge the wound. In other respects these wounds are 
treated on the same general principles as incised wounds. 

Punctured wounds are peculiarly a source of worry. They are 
most prone to become septic for two reasons; first, infection is very 
likely to be carried into the wound, and second, it is likely to be 
retained. 

The vulnerating instrument is usually unclean; portions of it may 
be broken off and retained; other foreign bodies, such as shreds of 
clothing, sources of infection, may be pushed in and overlooked, in- 
asmuch as the narrow tract makes exploration difficult. The tissues 
are not divided but are pushed apart, and tend to close as the instru- 
ment is withdrav^n. The vessels are little wounded, so that bleeding, 
the best agent for disinfection, for washing out the invading micro- 
organisms, is wanting. 

The bottom of these wounds may be shut off from the surface, so 
that the oxygen-hating bacillus of tetanus finds there a congenial 
lodging. 

The treatment for all these reasons must be circumspect. In doubt- 
ful cases, it is better at once to lay open the wound and thoroughly 
disinfect and search for foreign bodies. In any event, the wound 
must be carefully syringed with cleansing solutions. Peroxide of 
hydrogen is particularly indicated if tetanus is anticipated. If sup- 
puration is threatened, early and free incision and drainage are 
imperative. 

Counter openings may be required to facilitate the removal of foreign 
bodies or inflammatory products. 

Lacerated wounds are characterized by the great destruction of 
tissue, comparatively speaking. "They are peculiarly the product 
of modern times." The machinery of rapid transit and manufactory 
is largely responsible. Boiler explosions contribute a number. Gun- 
shot wounds, especially of the face, are likely to be lacerated wounds. 

The manner in which the injuries are produced, the tearing and 
crushing of the tissues, gives such injuries the following character- 
istics: 



LACERATED WOUNDS. 65 

(i) There is slight primary hemorrhage. 

(2) There is frequently reactionary or secondary hemorrhage. 

(3) Shock is usually present. 

(4) Infection seldom fails to develop. 

(5) Deformity is likely to result. 
The following are the reasons : 

(i) Primary hemorrhage is slight, out of all proportion to the 
destruction of tissue, because the coats of the torn vessels 'curl up and 
contract, the ragged, uneven surfaces favor coagulation, and the 
presence of shock lowers the blood pressure. 

(2) Reactionary hemorrhage occurs because of the smaller vessels 
losing their plugs of clotted blood when the blood pressure is restored. 
Secondary hemorrhage occurs because of the suppuration, which is 
the rule rather than the exception, unless prevented by treatment. 

(3) Shock is always present in some degree because of the injuries 
to the nerve trunks. In crushing injuries to the extremities, it is 
sometimes difi&cult to relieve shock until the mangled nerves are 
completely divided by amputation. Sometimes under these circum- 
stances, the shock is immediately fatal. 

(4) Infection is coincident with the injury because of the grime 
which is ground into the tissues. The vitality of the tissues adjoining 
those which were killed outright is greatly lowered, and the power to 
resist microbic invasion lost. An invading germ and lowered vitality 
are the two factors always essential to suppuration. 

Treatment of Lacerated Wounds. — (i) Hemostasis, (2) relief 
of shock, (3) antisepsis, (4) support. 

(i) Hemostasis is usually not difficult. It may be necessary to 
catch up a bleeding vessel with forceps and ligate, but more often 
pressure with gauze pads wrung out of hot normal salt solution suffices. 
Unless the hemorrhage is severe, sterilize the adjacent skin with soap 
and water, bichloride, or alcohol, before beginning exploration. 

(2). Shock is treated on general principles. Maintain the body 
heat, lov/er the head, and keep the patient quiet. In severe cases, 
injections of adrenalin and salt solution are to be employed. (See 
shock.) 

(3) Antiseptic measures follow the arrest of hemorrhage and shock. 
5 



66 WOUNDS. GENERAL PRINCIPLES. 

Begin by covering the wound with sterile gauze, and then scrub the 
adjacent skin with soap and sterile water, then with bichloride, 1-2000, 
and finally with alcohol. Next cleanse the wound. By repeatedly 
flushing with normal salt solution or very weak bichloride or other 
antiseptics, an effort is made to rid the tissues, as much as possible, of 
dirt and debris. 

Porter, of Fort Wayne, says with regard to cleansing wounds 
(American Medicine, September, 1906), that it is an easy matter to 
overdo in our attempts to render an accidental wound aseptic. By 
the use of too vigorous scrubbing, too harsh mechanical means, 
too hot water, or too strong antiseptic solutions, more harm than good 
may be done. The resisting pgwer of the tissues is perhaps the most 
potent single factor in preventing infection, and it may be diminished 
by too much antiseptic zeal. We must remember that in spite of our 
efforts some germs will be left for nature to take care of, and we must 
not make it impossible for her to do it. "Personally," says Porter, 
*' I find myself using more care, more time, more patience, more soap, 
more water, and less vigorous scrubbing, less curettement, and weaker 
germicides." The grime and grease of machinery are most readily 
removed by pouring on gasoline. 

It is not always possible to determine to what extent the tissues are 
fatally injured. In the case of crushed wounds of the extremities, 
it may be necessary to wait until a line of demarcation appears, so 
that no useful tissues shall be unnecessarily sacrificed. 

Drainage is a matter of antisepsis. It is a sine qua non in the case 
of lacerated or crushing wounds, but there is usually little trouble in 
this respect for the reason that these wounds are not sutured and 
drainage is provided for in the dressing. 

(4) Suture of the skin wound is not possible, as a rule, but certain 
of the deeper structures may demand such repair. A divided nerve 
trunk, tendon, or muscle requires approximation. Sometimes coapta- 
tion of the wound, even though incomplete, will lessen the- time 
required for granulation. 

The dressing must fill two requirements; it must absorb the dis- 
charge and also keep out infection. The most commonly employed 
dressing consists of a loose but liberal covering of bichloride or borated 



INFECTED WOUNDS. 67 

gauze applied to the wound, and over this a covering of absorbent 
cotton held in place by a bandage, which is applied for the purpose 
also of giving -equal pressure and support to the wounded tissues. 
The frequency with which the dressing must be changed will depend 
upon the degree of infection. 

^ The author has derived much satisfaction in the treatment of this 
class of wounds from the use of the ointment mentioned on page 370. 
After the wound has been cleansed, the ointment is applied and the 
whole covered wdth gauze and bandaged. It tends to relieve tension 
and pain and promote repair. The gauze does not adhere to the 
surface of the wound and so the change of dressing is facilitated. 

The aim in general is to disturb the tissues as little as possible, 
and no change is made except to meet the indications of some phase 
of sepsis. 

Infected wounds may not be recognized as such from the first, but 
soon the processes of inflammation manifest themselves. Pain, red- 
ness and swelling, accompanied by certain constitutional states, such 
as fever and rapid pulse, are the cardinal symptoms. 

The sepsis may produce no results more severe than temporary 
disturbances of the character named. On the other hand, it may 
result in suppuration, which prolongs repair and produces unwelcome 
cicatrices; or, even worse, the infection may spread so rapidly as to 
involve extensive areas, rendering the tissues brawny with serous 
exudates and overwhelming the heart and kidneys with toxins before 
suppuration has time to appear. It is these uncertainties v-hich 
make infection so much to be feared, and make its prevention the 
largest element in the treatment of ordinary wounds. When once the 
sepsis has a definite foothold in a wound, the treatment has two 
objects: to destroy the germ and remove and neutralize its toxins; 
and to support the tissues in their struggle. 

Irrigate the w^ound cavity at least once daily with weak antiseptic 
solutions, such as bichloride, peroxide, lysol, or iodine; provide the 
freest exit for the exudates, employing drainage tubes, if there is a 
cavity. Never pack a suppurating cavity with gauze. Apply a 
moist gauze dressing, moistening it with alcohol, bichloride or boric 
acid, or other antiseptic solutions, or, what is perhaps as well, with 



I 



68 WOUNDS. GENERAL PRINCIPLES. 

normal salt solution. This may or may not be covered with absorbent 
cotton. AVhatever other qualities the dressing may possess, it must 
be absorbent. Sometimes in the case of the extremities, prolonged 
immersion in warm normal salt solution does good. 

After granulation once begins, it may be stimulated and the wound 
kept healthy by the use of dusting powders, antiseptic ointments, 
or balsam of Peru. The latter has been lately very highly recom- 
mended, in the treatment of wounds generally. 



CHAPTER X. 
WOUNDS OF SPECIAL REGIONS. 

WOUNDS OF THE SCALP. 

Certain anatomical features determine the special character of 
scalp wounds, and must be kept in mind in prognosis and treatment. 

The blood vessels converge toward the vertex; they are the occipital, 
posterior auricular, superficial temporal, supraorbital and temporal, 
any one of which may give rise to troublesome bleeding, and all of 
which are subcutaneous instead of subaponeurotic, as elsewhere. 

They are firmly connected with the dense tissue of the scalp and 
for that reason do not readily contract when divided; for this reason 
the bleeding from scalp wounds is copious and without much tendency 
to spontaneous arrest. The vessels are somewhat difficult to catch 
with artery forceps. 

The aponeurosis of the occipito-frontalis is the dividing line in 
prognosis: wounds that do not penetrate it are less likely to become 
infected, nor do the conditions favor spread of infection. A wound 
perforating the aponeurosis is always a matter of concern, for owing 
to the loose cellular tissues which connect the aponeurosis with the 
pericranium, an infection may spread very rapidly and in every direc- 
tion. 

All scalp wounds are presumably infected, yet the free bleeding 
minimizes the infection, and the rich blood supply of the tissues favors 
repair. 

Scalp wounds do not gape unless the aponeuiosis is divided, and 
contused wounds often resemble incised wounds. 

Contusions may result in the formation of hematoma beneath the 
skin, but they are of little moment. Evaporating lotions are sufficient 
to hasten absorption. 

A severer injury may cause a hematoma under the aponeurosis 

69 



70 WOUNDS OF SPECIAL REGIONS. 

and such a tumor is likely to be extensive. It may be the source of 
error in diagnosis, giving the examining finger the sensation of a 
depressed fracture, being hard around the borders, and soft in the 
center. If the tumor is of such size as to put the skin greatly on the 
stretch, it may be punctured. This is preferable to incision, for there 
is less chance of infecting the exudate. 

Absorption always takes place so that the least interference possible 
is the best treatment. 

A hematoma may form under the pericranium, usually in children 
in whom the bone has a rich vascular supply. Here, also, it is ab- 
sorbed in time, and intervention is rarely, if ever, necessary. 

Open wounds. — The treatment of these wounds, of whatever 
character, may be expressed in certain general formulae. 

The first step consists in cleansing the hair of the blood, which is 
not always an easy task. Warm water is best to dissolve out the clots, 
or peroxide of hydrogen. 

The next step consists in removing more or less of the hair, depend- 
ing upon the gravity of the wound. In all serious cases, the whole 
scalp must be shaved. Begin by cutting the hair with the scissors, 
and then apply the razor; the "safety razor" facilitates this work. 

Next cleanse the scalp with ether, to dissolve the oil which is always 
present, and follow this with alcohol; otherwise the ether will interfere 
with the soap and water cleansing which follows, and which is freely 
and vigorously applied. 

In the meantime, a light gauze packing prevents the soap and 
water running into the wound. Once the scalp is cleansed, the 
wound itself is to be cleansed. 

Strong antiseptics are distinctly to be avoided. Sterile water, 
normal salt solution, or peroxide are perhaps the best. An irrigator 
or syringe is not to be used, but the solution may be squeezed out of a 
compress into the wound. Be assured that every particle of foreign 
matter is out of the wound before considering repair. 

Complete hemostasis is an essential to rapid healing, and the time 
and patience spent in securing it are by no means lost. If the bleeding 
vessels cannot be ligated in the ordinary way, the ligature may be 
carried on a needle through the tissues surrounding the vessel. The 



WOUNDS OF THE PINNA. 7 1 

oozing may be entirely controlled by a few minutes' pressure with a 
hot antiseptic compress. The main thing is not to get discouraged or 
be in too great a hurry. 

The cleansing and hemostasis completed, the coaptation follows. 
In the case of contused wounds, the ragged edges are to be trimmed 
away. The suturing is an important step in facilitating reunion. 
Even wounds that do not gape heal all the more quickly for suturing, 
silk being probably the best material. . 

In many cases of incised wounds which are not deep, the suturing 
may be firm and no drainage required. In the great majority of cases, 
however, some form of drainage is necessary; it is attained by incom- 
plete suture, by a tube, or, following Von Bergman, by strips of gauze. 

If a large segment of the scalp has been loosened, every effort must 
be made to readjust and suture it accurately, though the drainage 
must be ample. Oftentimes with those who have been ev€n almost 
completely scalped, the results have been excellent. 

The dressing will usually consist of sterile gauze and absorbent 
cotton held in place by bandage. In the case of minor wounds, and 
where no infection is feared, it is sufficient to smear the line of suture 
with sterile vaseline and cover with llexible collodion. 

WOUNDS OF THE PINNA. 

Many forms of injury befall the ear. It may be bruised, cut or 
lacerated, and much or little of it lost. Even a slight loss is a dis- 
figurement, and any very serious loss of tissue results also in some 
disturbance of hearing. 

These tissues possess great vitality, and the completeness of repair 
after much mutilation is often surprising. Large portions of the 
ear may be cut off completely, and yet if immediately sutured in 
careful coaptation, union will occur. There may be some sloughing 
along the line of union, but eventually there is but little scar tissue left. 

In every case, then, of incised wound, an effort must be made to 
suture. The hemostasis must be complete, and if there is much 
laceration, the edges of the wound must be trimmed. Silk is the best 
suture material. 



72 



WOUNDS OF SPECIAL REGIONS. 



WOUNDS OF THE FACE. 

Accidental wounds of this region, more than any others, approxi- 
mate aseptic wounds. These wounds do not gape much; the tissues 
are very vascular, so that the conditions are most favorable for repair. 
The chief aim is to avoid scar tissue and the consequent disfigurement. 
To attain that end the suturing must be delicate, the coaptation per- 
fect. The sutures must be as small as possible and as few as possible. 

The subcutaneous stitch may be employed if the wound is extensive 
and deep. In ordinary incised wounds extensive dressings may be 
dispensed with and the line of suture may be covered with collodion or, 
as Von Bergman, who dislikes collodion, suggests, the wound may be 
amply protected by the scab formed by the dried exudates. 

WOUNDS OF THE LIPS. • 

Wounds of the lips are likely to bleed considerably, but the hemor- 
rhage is easily controlled by com- 
pressing the lip between the thumb 
and index finger, and then the 
coronary artery may be ligated on 
each side of the wound. 

Begin the repair in complete 
division by suturing the mucous 
membrane (Figure 55) with catgut. 
Suture the skin by continuous or 
interrupted suture of fine silk or 
catgut. The greatest care must be 
exercised when the border of the 
lip is reached; the coaptation must 

Fig- 55- — Suturing wound of lip. (Veau.) , . .1 i^ -ni, J- 

be exact or the result will be a dis- 
appointment. 

A small drain in the skin wound is usually advisable. 

WOUNDS OF THE TONGUE. 

Wounds of the tongue, which are not as infrequent as one might 
expect, may give rise to a disagreeable hemorrhage. 

The tongue is to be drawn out of the mouth and compressed with 




WOUND OF THE TONGUE. 73 

the fingers above the wound or by a pair of forceps covered with 
rubber tubing or with gauze. (Fig. 56.) 

Suture the bleeding points, employing deep sutures of catgut, No. 3. 
Every quarter hour the mouth should be washed with a solution of 
chloral, 2 grains to the ounce, until the oozing and pain have subsided. 



Fig. 56. — Suturing wound of tongue. A, tongue controlled by tenaculum forceps. B, fiirst 
suture passed and tied. C, second suture passed, using the Reverdin needle. (Lejars.) 

WOUNDS OF THE EYE-LID. 

A wound of the eye-lid is to be repaired like a wound of the lip, by 
two lines of suture. Suture the mucous membrane Vvith fine catgut. 
Begin the suture of the skin at the free border, where the edges of the 
divided tarsal cartilage are to be very accurately coapted (Fig. 57). 
If drainage is used, it must be small and project from the middle of 
the wound. 

WOUNDS OF THE NECK. 

One has but to consider the multiplicity of the structures in the neck 
to realize that wounds of this region are likely to be complicated. 



74 



WOUNDS OF SPECIAL REGIONS. 



Whether the wound be incised or contused, a stab or a gunshot 
wound, there are the dangers that arise from hemorrhage, asphyxia, 
and infection. 

The most common wounds, perhaps, are those which arise from 
attempts at suicide. That these attempts are often abortive, and 
the danger done much less than one might expect, are due to the 
fact that the tissues are yielding and the vessels recede as the head is 
thrown back; the knife may be directed against the lower jaw or spend 
its force on the cartilages or hyoid bone; the arm may lose its force at 
the moment the larynx is opened, or from failing resolution. In these 
attempts at suicide, the w^ound in right-handed people usually begins 
on the left side high up, and runs obliquely downward to the right, 

becoming less and less deep. Not 
infrequently the wound may appear 
jagged, or give the impression of 
two or three slashes, from the 
folding of the skin before the pres- 
sure of the knife. 

In the graver cases, hemorrhage 
is usually the first consideration. 
If a carotid is wounded, a geyser of 
blood spurts out and the patient's 
life is in the hands of the first comer, for there is no time to call for 
skilled aid. If the internal jugular is wounded, the hemorrhage 
is scarcely less dangerous and perhaps even more difl&cult definitely 
to control. Air may enter the venous circulation and death imme- 
diately ensue. In either case anything but intelligent first aid will 
fail. 

The carotid maybe controlled by pressure downward and backward 
at the base of the neck, compressing the vessel against the transverse 
process of the sixth cervical vertebra; or the bleeding may be tempor- 
arily controlled by direct pressure on the bleeding vessel in the wound. 
When the surgeon arrives upon the scene, he finds the wound filled 
with a great clot, for it cannot be expected that the first aid will do 
anything more than partly check the bleeding. His first effort must 
be to cleanse out the clots and locate both ends of the bleeding vessels, 




Fig. 57. — Incised wound of upper lid. 
Tarsal cartilage sutured first. (Veau.) 



WOUNDS OF THE EYE. 75 

clamp them, and ligate. Blind clamping of the tissues en masse is 
absolutely unsurgical. If the ends of the divided vessel cannot be 
located, the wound is to be enlarged over the course of the vessel, 
using the anterior border of the sterno-cleido mastoid muscle as a 
guide. If the character of the wound or the region preclude that, 
then the artery must be exposed below the wound and ligated. It may 
happen, especially in secondary hemorrhage, that the carotid on the 
opposite side also may need to be ligated either temporarily or per- 
manently. 

The internal jugular may be difficult to expose and ligate because 
of its thin and friable walls. Even small openings in the vessel 
may call for circular ligation, for lateral ligation is usually unsatis- 
factory. Outside of the hospital, suture can scarcely be considered. 

If the trachea^ in its upper part, or the larynx is opened, it is better 
to do a tracheotomy lower down and attempt repair of the wound. 
In many cases, however, if the wound is not extensive, it is sufficient 
to close the wound by flexing the neck and leaving off the sutures. 

If the esophagus or pharynx is perforated, repair should be at- 
tempted, but drainage must be employed and the external wound left 
open. 

If infection or inflammation of the respiratory tract arises, it can be 
treated on general principles. 

Divided nerves should be repaired if possible, although often the 
difficulties are too great to surmount. 

WOUNDS OF THE EYE. 

Morrison, of Indianapolis (Indiana Medical Journal, Feb., 1907), 
has defined the injuries of the eye-, whose treatment must most often 
be instituted by the general practitioner. From the diagnostic point 
of view, he classifies them under two heads: 

(a) Those without superficial lesions of the ball. 

(b) Those with more or less extensive open wounds. 

The first may lead the practitioner into grievous error in prognosis 
and injudicious lack of treatment. No blow over the eye should 
ever be considered lightly. While the majority of such cases lead to 



76 WOUNDS OF SPECIAL REGIONS. 

no serious consequences, the exceptions are of sufficient frequency 
to be of importance. 

It is possible for the so-called "concussions" to lead to subsequent 
inflammation or degeneration of the deeper structures of the eye. So, 
then, though no treatment is to be instituted in the absence of symp- 
toms, yet the case must be kept under observation for some time, the 
vision tested, irregularities of the pupil noted, and evidences of in- 
flammation sought for. 

On the other hand, there may be a hemorrhage into the anterior 
or posterior chambers, accompanied by pain, protrusion of the eye-ball, 
and swelling of the lids. 

Put the patient to bed at once and apply iced cloths to the eye, this 
treatment to be kept up until the symptoms begin to subside, when 
it is probable that the blood has clotted and the hemorrhage ceased. 

In addition to, or instead of hemorrhage, there may be disarrange- 
ment of the retina, lens or iris, accompanied by disturbance or destruc- 
tion of vision. 

Put the patient to bed in a darkened room, and drop into the eye 
a solution of atropia, four grains to the ounce, followed by the appli- 
cation of cold cloths for at least twenty-four hours. Later a. bandage 
is to be applied and the patient permitted to go about. 

Any subsequent disturbance calls for an examination by an oculist. 

Deep, penetrating, non-infected wounds of the globe are serious 
in various degrees, depending upon the region involved, though they 
usually heal kindly. Injuries of the sclero-corneal junction or ciliary 
body often lead to sympathetic ophthalmia, and may require early 
or late enucleation. 

The treatment is simple. Prevent infection by the free use of boric 
acid solution, followed by one or two drops of the atropine solution, 
and the application of a sterile eye dressing. Rest in bed is indicated. 

Every wound of the sclera of any moment requires suture, which is 
the best means of preventing infection. Infected wounds require 
an immediate and circumspect treatment. 

If the vitreous is involved, the eye is almost certain to be lost. The 
prognosis is somewhat better if the cornea alone is involved. 

The eye is to be irrigated with warm, sterile, saturated solution 



WOUNDS OF THE EXTREMITIES. 77 

of boric acid, followed by a few drops of the atropine solution, the 
whole to be repeated every two or three hours, until the redness passes 
away. In the meantime, heat or cold is to be applied, depending upon 
which gives the most comfort, except in the case of the cornea, where 
heat is always the better application. 

Morrison recommends as the best eye pad, several thicknesses of 
sterile gauze held in place by a single thickness of bandage or a strip 
of adhesive plaster so that it can be frequently changed. 

To sum up, then, the chief ends of the emergency treatment are 
two; asepsis and conservation. Only very rarely will the question of 
enucleation present itself as an emergency. The careful examination 
which should be given every injured eye, should be preceded by a 
regulated asepsis. Prepare the hands; prepare the orbital and palpe- 
bral regions by patient washing with warm sterile water and soap, 
avoiding all pressure or rough handling which may aggravate the 
ocular lesions. Cleanse the conjunctiva of the grosser dirt and im- 
mediately instill a few drops of cocaine solution. In a few minutes 
the cleansing of the globe and palpebral may be completed without 
pain, and a careful examination made and the treatment instituted. 

If suture is required, use a small curved needle held with a forceps, 
employing catgut No. oo, and above all, a minute care and a light 
hand. 

The suture should not pass through the entire thickness of the 
sclerotic coat, but only through the conjunctiva or the most superficial 
layers of the sclera. The reunion will usually be perfect if the sutures 
are carefully passed and slowly tied. (See, also, Foreign Bodies.) 

WOUNDS OF THE EXTREMITIES. 

Wounds of the extremities call for varied application of all the 
principles of treatment of wounds, hemostasis, antisepsis and 
suturing. 

Only thorough familiarity with these principles will give one address 
in the management of the individual cases, for no two injuries are 
exactly alike. It will be advantageous to exemplify these principles 
with special reference to wounds of the extremities. 



78 



WOUNDS OF SPECIAL REGIONS. 



AN INCISED WOUND OF THE WRIST. 

In such a case, there may be copious bleeding; a large artery, the 
radial, for example, may be involved. Begin the treatment by eleva- 
ting the arm and applying circular constric- 
tion to secure a temporary hemostasis (Fig. 
58). Next cleanse the field and then the 
wound itself. 

Separating the lips of the wound, locate 
and clamp the superficial veins (Fig. 59). 
It is not likely that they will need to be 
ligated. Search for the artery; both ends 
must be tied and it is not necessary to 
separate the companion vein. The two are 
ligated together (Fig. 60). 

Release "the constrictor. The oozing is 
nearly always very free at first, due to 
temporary vaso-motor paralysis, but it is 
not at all serious. 

Apply compresses for a few minutes, 
thus arresting the capillary bleeding, and 
if a new point spurts, apply a ligature. 
Inspect the wound carefully and if a tendon 
or nerve is divided, it must be immediately 
sutured (see page 250 el seq.). 

A STAB WOUND OF THE THIGH. 

(Fig. 61.) 

The femoral has been wounded and the 
hemorrhage is furious. Direct an assistant 
to make firm digital pressure over the artery 
as it crosses the pubes, nor must this pres- 
sure be relaxed. If his fingers tire, a second 
assistant may press upon the fingers of the 
first (Fig. 62). Enlarge the wound freely in both directions in the 
course of the artery. Sponge out the clots; recognize the aponeurosis 




Fig. 58. — Incised wound of wrist 
Tourniquet applied. (Veau.) 



A STAB WOUND OF THE THIGH. 



79 



and divide it in order to expose the artery; isolate the artery by care- 
ful blunt dissection and find the two ends, which is often difficult 
when the artery is completely divided (Fig. 63). 

When both ends are found, ligate with catgut No. 3, or silk No. 2, 
(Fig. 64). Tie the injured vein both above and below. It is to be 
tied separately from the artery (Fig. 65). The possibility of including 
a nerve in the ligature must always be borne in mind and no ligature 
is to be finallv tied until certain that no nerve is to be thus com- 




FiG. 59. — Incised wound of wrist. Bleed- 
ing vessels clamped. (Veau.) 



Fig. 60. — Incised wound of wrist. 
Vessels legated. (Veau.) 



pressed, to become later a source of pain. Remove the pressure and 
catch any more vessels that might bleed; employ free drainage and 
suture incompletely. 

Apply sterile gauze dressing, absorbent cotton, and a bandage, 
making moderate pressure, and maintain the limb in moderate ele- 
vation. Renew the dressings on the third day, and if there are no 
complications, remove the drainage. Remove the sutures about the 
eighth day. 

Certain complications may arise. If the ligatures were imperfect, 



8o 



WOUNDS OF SPECIAL REGIONS. 



hemorrhage may ensue; the operation has to be repeated again. 
If infection occurs, if the temperature reaches ioi° F., open up the 
wound and establish better drainage, which is the best means of 
preventing secondary hemorrhage. Gangrene sometimes follows the 





Fig. 6 1. — Stab wound of thigh. 
(Veau,) 



Fig. 62. — Stab wound of thigh. Com- 
pressing artery while the wound is en- 
larged. (Veau.) 



ligation of a main artery. Watch the temperature of the extremity 
and look for pulsation in the arteries below the ligature. If pulsation 
is present, be in no haste to amputate. If gangrene does not develop 
before the fourth day, it is not likely to do so. 

Crushing and lacerating wounds of the extremities, as Lejars 



CRUSHING INJURIES TO THE EXTREMITIES. 8 1 

says, give rise to the most perplexing problems of emergency surgery. 
The questions present themselves in this form: To amputate, or not 
to amputate? and if the latter, when, at what point and by what 
method? 

In order not to be vacillating in his treatment, every doctor must 
have his principle of action settled once for all. 

Lejars states his guiding principle and rule of action in this manner: 




Fig. 63. — Exposing the wounded vessel. (Veau.) 



A.bove all, save the patient's life; save the limb wherever possible, or 
at least limit the mutilation to the minimum. 

Clinically, he places these injuries in two groups: (a) those in which 
a segment of the limb is crushed or otherwise injured without periph- 
eral involvement, and (b) injuries extending from the hand or foot 
upward. 

(a) Suppose a case: An arm has been run over by the wheels of a 
heavy vehicle. The member is flail-like, although the skin is not 
broken, and there are no particular points of bleeding. Palpation 
6 



82 WOUNDS OF SPECIAL REGIONS. 

through the skin over the injured segment shows that the deeper 
structures have been reduced to a pulp, both muscle and bone. 

Still, below the wound, the radial and ulnar arteries are found to 
pulsate. This is an absolute indication against amputation. The 
immediate treatment must be limited to a careful disinfection of the 
member, the repair of any superficial wounds, a complete envelop- 
ment in absorbent cotton, and immobilization. 

The immobilization is an essential feature, for by that means any 
bending and stretching of the vessels is prevented and repair favored. 




Fig. 64. — Isolating andvligating the artery. 
(Veau.) 



Fig. 6 



'5- — Ligating the vein. (Veau.) 



If the skin is broken and the bone crushed or shattered and exposed, 
the injury is a compound fracture and is to be dealt with accordingly, 
but the prognosis always depends upon the blood supply. 

If in the case instanced, there is absolutely no pulsation in the prin- 
cipal arteries, it is certain that a part of the limb is lost; yet an im- 
mediate operation is not indicated. There are two reasons for this; 
first, that the shock may subside, and second, that too much of the 
limb may not be sacrificed, which latter an immediate amputation 
nearly always means. 



CRUSHING INJURIES TO THE EXTREMITIES. S^ 

Proceed to a most rigorous disinfection and await a line of demar- 
cation. This is the rule to which there are two exceptions, one 
apparent, and the other actual. 

If the injury is a crushing one and the member hangs by shreds 
of tissue, there is absolutely no use in waiting; but the completion of 
the ablation does not require an amputation, it is merely what Lejars 
terms a "regularization." 

Trim up the tissues spaiingly and remove enough bone that a 
proper stump may be formed, and' then patiently cleanse the wound 
with hot sterile water or normal salt solution, followed by alcohol. 
Suture completely and then cover the wound with sterile gauze sat- 
urated with alcohol; finally cover all with a thick layer of cotton firmly 
bandaged. 

Almost ahvays by this means a better functional result may be 
obtained than by a formal amputation quite above the site of 
injury. 

There is an actual exception to the rule of conservatism. The 
case is seen late and there are already signs of approaching injection. 
It is not safe to delay and risk the sepsis which menaces. It is better, 
under such circumstances, to proceed to immediate amputation. 

(b) Crush or laceration extending from the hand or foot upward. 

Suppose you are called to treat the foot and part of the leg, or a hand 
and part of the forearm, which have been crushed and lacerated. 
The member appears injured beyond remedy. Will you immediately 
proceed to amputate ? By no means — or at least, not as a rule. 

If the case is seen immediately, the first effort should be devoted to 
combating shock and infection. 

It is not altogether on account of shock that one waits; there are 
other even more important reasons. The first is that you may not 
amputate high enough; the second, that you may amputate too high. 
One cannot always determine from the first how high the devitalized 
tissues extend. There may be vascular injuries or muscular lacera- 
tions which are concealed by a sound integument, and which may 
later be the source of gangrene. Out of this grows the necessity of a 
secondary amputation, which is always a matter of chagrin to the 
surgeon and an element of danger to the patient. 



84 WOUNDS OF SPECIAL REGIONS. 

On the other hand, tissues which appear devitalized may finally 
survive and thus preserve a function which might otherwise have been 
sacrificed. 

it is true that a few inches more or less of the arm or leg, for instance, 
may make no great difference in the usefulness of the stump; it is 
quite otherwise when the question is that of amputating immediately 
above or below the elbow or the knee, or through them. Nor do rules 
of conservation apply with equal force to the foot and the hand. 

As Simons, of Charleston, S. C, says (International Journal of 
Surgery, August, 1906), injuries of similar degree affecting the upper 
or lower extremity demand different treatment, because of the much 
greater freedom of collateral circulation in the former rendering 
gangrene less probable. 

Where conservatism or excision would be proper in the upper 
extremity, amputation w^ould be called for in the lower limb. 

Extensive comminution and loss of bone of the foot may demand 
amputation because, if saved, the member may be useless as a means 
of locomotion, and should give way to a vastly more useful artificial 
limb. 

Great laceration of the soft parts with free comminution of bone 
and injury to vessels, always demands amputation, for the destruction 
of the skin of the heel and sole will result in a cicatrix which can never 
bear the weight of the body and may never be anything but a source 
of suffering and discomfort to its possessor. 

But aside from these exceptions and others to be noted, the rule 
holds in this class of injuries, to av^oid amputation and devote one's 
skill to preventing infection. The prevention of infection is the 
sine qua non; if the efforts in this direction are going to be half-hearted, 
it is better to amputate at once. 

Immediate amputation, again, is indicated if the v ound is seen some 
hours after the accident, and is found soiled and dirty and manifestly 
infected. 

Under these conditions, conservatism is not the best course, for there 
are too many chances that the attempt at disinfection will fail; that, in 
spite of the best efforts, sepsis will arise. Or if there are already present 
the symptoms of dangerous sepsis, it is no longer a question of saving 



TREATMENT OE INJURIES TO THE HAND. 



85 



a limb, but of saving a life, and it will be the part of conservatism to 
amputate ■veil above the suspected level. 

With regard to the conservative treatment of these severe crushing 
and lacerated injuries of the bands and feet which most surgeons would 
be prone to amputate, Reclus, of Paris, has emphasized the value of 
thorough and patient d^>^^'' f: i 11 cf the skin and then of the wound, 
together with a trimming a , .:■ . ' .be de-.italized fragments of skin and 
bone. He then "emb:.:r_ _-,■' iL:e member in crauze saturated with an 



antiseptic pomade, cro 



inio all the recesses of the wound, and the 




whole covered by a ihick dressing of absorbent cotton and bandaged. 
This dressing is lef: undisturbed until repair is conivleie unless the 
temperature should rise or a disagreeable odor develop. 

Joseph Marsee (Ind. iied. 
Jour., April, 1896J has made 
some useful observations with 
respect to the tre2t:neiit oj co:,!- 
mon injuries oj tlie haud, which 
are well worth repeating and 
which, as he points out, appeal 
especial. y to the young man just 
beginning his life's work, for 
such will probably constitute the 
bulk of his surgical practice for 
some years. There is a natural 
tendency, in the popular mind, 

to measure an injury by the size of the member involved, and the man 
who would insist upon the best advice in other cases, v ill fly to the 
nearest doctor's sign when "only a finger" is involved. But JMarsee 
concludes, from his own experience, that the young practitioner is 
an accomplice in spoiling a good many hands before he learns to do 
them justice. On the other side, it is not too much to say that the 
best human skill is none too good when employed in repairing injuries 
of the most mechanically perfect human member. 

The majority of these injuries occur in workers ^^ith machinery; 
the hand, therefore, is always soiled and generally greasy. This grease 
must first be removed. Nothing is better for this purpose than or- 



FiG. 66. 



-Ball of gauze for support of fingers. 
(Marsee.) 



86 



WOUNDS OF SPECIAL REGIONS. 




Fig. 67. 



-Thumb pinched off leaving square- 
ended stump. (Marsee.) 



dinary gasoline or benzine, which may be poured into the hand directly 
from the bottle. The fluid will find its way into the smallest recesses 
of the wound, washing out the grime and preparing the way for the 

other antiseptics. The benzine 
is poured on until all the grease 
is removed, and -the disinfection 
is completed in the ordinary way. 
Even slight wounds of the 
fingers and palms should be 
treated by enforced rest by a 
splint or plaster-of-Paris dress 
ing, complete enough to preclude 
all motion. This prophylaxis is 
not regarded as unnecessary by 
those who have seen the miost 
marked deformities; the gravest 
constitutional disturbances, and 
even death, result from trifling wounds of the hand. Enforced rest 
which leaves nothing to chance, to caprice or the patient's meddling 
is alone reliable. Under such treat- 
ment, the rapidity with which alarm- 
ing symptoms sometimes disappear is 
truly remarkable. If a planter casing 
is used, it should extend from several 
inches above the wrist to the extreme 
tips of the fingers, the thumb being 
also enclosed if necessary. 

When finger wounds are extensive 
and parallel with the long axis, it is 
better not to suture them at once, for 
the swelling will generally be extensive 
and the stitches will cut out. After 
the inflammation has subsided, the 
edges may be freshened and approxi- 
mated. Nor does Marsee advise immediate splinting in the case of 
crushing injuries of the fingers, for fear that the circulation may be 




Fig. 68 



Amputation com- 
(Marsee.) 



TREATMENT OF INJURIES TO THE HAND. 



87 




Pig. 69. — Amputation of index finger. Head 
metacarpal retained. (Marsee.) 



interfered with. However, that the crushed member may not be 
wholly unsupported, a soft ball covered with cotton and wrapped with 
gauze is applied to the palm so that the fingers may be spread out over 
it comfortably (Fig. 66), and Ithe 
w^hole dressed with absorbent 
cotton and lightly bandaged. 
The ball, as Marsee indicates, 
though unsightly and bulky,, has 
no other fault; it is light, ab- 
sorbent and wonderfully com- 
fortable, and needs only a trial 
to be appreciated and adopted. 
It should be used until the tis- 
sues are beyond danger, though 
it takes several days, a week or 
a month. No time is lost, for 

healing cannot begin until vitality is restored, and this will always be 
slow in such cases, a fact which should be brought thoroughly to the 
patient's knowledge from the beginning, that the doctor may not be 

blamed for the tardy convales- 
cence. 

With regard to methods of 
amputating fingers, opinion is 
divided on the question as to 
which is the more desirable, a 
palmar flap or a slightly longer 
finger with a dorsal flap cover- 
ing the stump. 

There can be no doubt that a 
palmar flap is desirable, and 
. , . , ^ ^^ , Marsee believes in securing it, 

Fig. 70. — Amputation of mdex finger. Head ^ , , 

of metacarpal removed making much more eveu at the eXDCUSe of Sacrificing 
sightly hand. (Marsee.>) 

more of the finger. If more 
than half the phalanx is gone, it is always better, in his opinion, to 
amputate at the joint line and thus avoid a flexed stump. 

If a portion of the distal phalanx remains, the nail should be re- 




WOUNDS OF SPECIAL REGIONS. 




Fig. 71.7— Loss of ring finger. 
Dorsal view. (Marsee.) 



moved and the matrix dissected before 
the flap is adjusted or some deformed 
fragment of nail may be left to vex the 
patient. It is better in removing a finger 
at a joint, to cut oft the knobby projec- 
tions of the condyles on the palmar surface 
and to scrape off the exposed cartilage. 

If the finger is pinched off' squarely, 
one must always insist in removing 
enough of the bone to give a good flap, 
for if the patient has his way and the 
stump heals by granulation, the result 
will be unsatisfactory and the doctor, 
eventually, will have to bear the blame 
(Figs. 67,' 68). 
If the whole finger requires amputation, the head of the metacarpal 

bone will require special attention 

and the procedure will be dift'erent 

with the diff'erent fingers. 

Remove the heads by oblique 

section in the case of the index and 

little fingers (Figs. 69, 70). Gen- 

erafly remove the head of the meta- 
carpus in the case of the ring finger, 

cutting back far enough to let the 

heads of the adjacent bones fall to- 
gether (Figs. 71, 72). 

Do not remove the metacarpal 

head of the middle finger unless 

the appearance of the hand is 

the chief consideration. Marsee 

states as the reason for this, that 

it tends to let the other fingers 

fall away from the thumb and 

thus interferes with ready apposition ,/i,Trdiy7o';?ced°wh1„*lis?afha?f''S 

/T7' ^.^\ the metacarpal bone is excised. 

V-Tlg- /3)- (Marsee.) 




INJURIES TO THE THORAX. 



89 



INJURIES TO THE THORAX AND ABDOMEN. 
INJURIES TO THE THORAX. 

Certain elementary notions must be clearly comprehended and kept 
in mind in the diagnosis of these injuries. These notions re \' ( k the 
anatomy, pathology and symptomatology of the thorax. Une must 
keep in mind the location of the principal vessels of the che.^t \, all and 
mediastinum; the relations of the viscera to the ribs; and the normal 
areas of resonance and dullness. In additinn, it is neco-sarv to re- 
call the signs and significance 
of the principal primary com- 
plications possible in any 
form of serious violence to 
the thorax, viz.: hemoptysis, 
hemothorax, pneumothorax, 
emphysema and hemio-peri- 
cardium. 

Hemoptysis^ following an 
injury to the thorax, what- 
ever its nature, is significant 
of one thing — that the lung 
has been involved. The de- 
gree of injury may be in a 
manner estimated by the 
amount of blood expector- 
ated. In the dangerous cases, 
the blood pours from the 
w^ounded lung tissue into the bronchus and gushes from the mouth. 
In other cases, there is only a shght spitting of blood, leading to the 
belief that the lung has not been seriously torn. It might be mistaken 
for a hematemesis, but the presence of rales in the bronchus of the af- 
fected side (or of both) and the Hght color of the blocd and its admix- 
ture with air, point to the character of the hemorrhage. 

Hemothorax, an accumulation of blood in the pleura, is nearly 
always the result of injury to the lung, although, of course, the internal 
mammary artery or the intercostals may occasionally be the source of 




Fig. 73. — The stump of the index finger 
falls awav from thumb when head of middle 
metacarpal has been removed. (Marsee.) 



90 WOUNDS OP SPECIAL PvEGIONS. 

the extravasation. Gravity determines where the blood will accumu- 
late and therefore the patient's position will modify the physical signs. 

The symptoms and signs are both modified by the quantity of blood 
and the rapidity with w^hich it is poured into the pleural cavity. In 
the slighter forms, there is scarcely any disturbance of breathing and 
only slight dullness over the base of the lung. 

In the graver forms, the lung is collapsed and crowded toward the 
hilum, so that there are symptoms of asphyxia added to those of in- 
ternal hemorrhage. The face is pale, the skin moist and cold, the 
patient is impelled to sit up and gasps for breath, the pulse is rapid 
and thready, and the patient may thus go on to death. Inspection 
reveals a slightly bulging chest wall; percussion, a comiplete dullness; 
and auscultation, an absence of fremitus and of the vesicular murmur. 

Often there is an immediate rise of temperature, due to absorption, 
and which is to be distinguished from the temperature of infection 
by its earlier appearance. 

No attempt to evacuate the extravasated blood is to be made in 
the moderately severe cases; in others, of more urgency, an aspiration 
may give some temporary relief, tiding the patient over a critical point. 
Finally, in rare cases the magnitude of the hemothorax will be such as 
to demand an immediate intervention with the purpose in view of 
exposing the lung and repairing the wound in its substance. Subse- 
quently, even if the case is mild, infection may occur and is to be treated 
as any other empyema. 

Pneumothorax. — Air may enter the pleural cavity from without 
through an opening in the chest wall, or from within through a rup- 
ture in the lung tissue. In the first case it enters during inspiration, 
and in the second, during expiration. 

The physical signs and symptoms grow out of the pressure within 
the pleural cavity and the consequent collapse of the lung. The chest 
wall on the injured side is distended, the intercostal spaces bulged out, 
the viscera are displaced, the ribs motionless, the vesicular murmur 
absent; the symptoms are principally those of dyspnea. 

If there are no complications, the air is gradually absorbed and the 
function of the lung restored. 

In extreme cases, puncture will relieve the intrapleural pressure; 



CONTUSIONS OF THE CHEST WALL. 9I 

and in the case of a valvular wound in the chest wall, which permitted 
entrance of the air but not its exit, enlargement of the wound is indicated. 

If air and blood accumulate simultaneously — if a hetno-pneumothorax 
exists — the physical signs will be altered, but not the symptoms. 

Emphysema. — The subcutaneous cellular tissue may become charged 
with air and practically the whole body be involved. It is nearly 
always due in the marked cases to puncture of the lung by a broken 
rib. The air escaping from the lung is prevented by the close con- 
tact of the pleural surfaces from entering the pleural cavity and is 
forced into the loose tissues of the ruptured chest wall. 

In other rarer cases the inner aspect of the lung is wounded and the 
air escapes into the tissues of the mediastinum, and follows them up 
into the neck. 

In ordinary cases no treatment is indicated and the air is soon ab- 
sorbed. However, in the severer forms the symptoms of asphyxia 
and cyanosis may supervene and then free incision over the infiltrated 
zone may be required. 

Hernia of the lung is a rare complication, and may be immediate or 
secondary. In the first case, the pulmonary tissue is forced through 
the breach in the chest wall by violent expiratory effort. In some 
cases where the skin is not broken, the hernia may be felt as a crepitant 
tumor beneath the skin. 

In the secondary cases, it forms more slowly, and is often due to the 
weakening of the thoracic wall by inflammatory processes. 

Hemo-pericardium may occur as the result of the wounding of either 
the pericardium or the heart, alone or together. 

The symptoms are those of syncope induced by the compression 
of the heart by the accumulated fluid; the signs are those of increased 
cardiac dullness. 'It is upon the signs that one must depend for the 
diagnosis, for the symptoms are often complicated by those of shock 
and by those which originate in other injuries in the thoracic region. 

CONTUSIONS OF THE CHEST WALL. 

Simple contusions of the thorax without fracture of a rib or the ster- 
num (which are considered elsewhere) and without symptoms pointing 
to internal injury need but brief consideration. 



92 WOUNDS OF SPECIAL REGIONS. 

There is often a degree of shock out of all proportion to the apparent 
lesion. 

A hematoma is likely to form. The pain and soreness disappear 
rapidly in the young, but are extremely persistent in the aged and the 
rheumatic. Strapping and massage with liniment are usually suffi- 
cient. 

In graver contusions, such as crushing injuries, it is rupture oj the 
lung which is always to be feared and which is usually evidenced by a 
large hemothorax. It must always be remembered that such an injury 
may occur without fracture of the ribs or sternum. 

Lejars cites the case of a boy eleven years of age, whose chest was run 
over by a wagon. He arose immediately after the accident but fell 
again unconscious, with blood pouring from mouth and nostrils. This 
hemorrhage did not long persist, but on the fourth day the temperature 
rose and he was taken to the hospital. His condition was alarming, 
the pulse weak with a rate of 104, his face cyanosed and the dyspnea 
intense; his heart was displaced to the right, and on the left side, were 
the signs of marked hemo-pneumothorax. A puncture removing 180 
G. of the exudate gave but temporary relief. The pulse continued 
to grow weaker and the dyspnea more intense, and an urgent interven- 
tion was indicated. The pleura was opened and the lung found re- 
tracted toward the hilum. In the upper lobe a tear was found, 7 cm. 
long and running upward and backward from the cardiac incisure. 
The wound gaped freely. The lung was drawn into the opening in the 
chest wall, and the pulmonary wound repaired with five sutures of silk 
which included considerable tissue to prevent their pulling out. The 
coaptation was perfected by a few superficial sutures. The upper 
lobe was sutured to the parietes and a tamponade with gauze com- 
pleted the operation. 

The outcome was unfortunate, for death occurred on the second 
day, but the autopsy found the lips of the lung wound well agglutinated. 
There was no costal fracture. 

The symptoms oj rupture of the lungs are the same whether a rib be 
broken or not: hemo-pneumothorax, abundant and increasing; 
a spreading emphysema; symptoms of grave anemia; to those may be 
added more or less quickly, the symptoms of pleural infection. 



WOUNDS OF PLEURA AND LUNG. 93 

The treatment, except in the cases of extreme urgency, must be con- 
servative and expectant. Shock must be combated, the patient kept 
absolutely quiet, and the dyspnea relieved by the sitting posture, and, 
if possible, by inhalations of oxygen. 

The anemia can be relieved by injections of small quantities of nor- 
mal salt solution frequently repeated. It may happen that after two 
or three days the symptoms will improve. 

A puncture will partly empty the pleural cavity affording great 
relief and, eventually, the remaining exudate will be absorbed. 

But in the worst cases, w^here the dyspnea is progressive and menac- 
ing, and the heart rapidly growing weaker, the responsibility cannot be 
shifted. It is indicated to operate at once, to open up the thorax and 
repair the tear in the lung, to do an urgent thoracotomy (see page 381). 

OPEN WOUNDS OF THE THORAX. 

Non-penetrating wounds of the chest wall are of slight significance 
and are to be treated on general principles. 

Penetrating wounds of the thorax derive their significance from the 
particular viscera and vessels which may happen to be involved. 
On the clinical basis, then, these wounds may be divided into three 
classes: 

A. Wounds which involve the pleura or lung. 

B. Wounds which involve the pericardium and heart. 

C. Wounds which involve the diaphragm. 

A. WOUNDS OF THE PLEURA AND LUNG. 

In whatever manner the wound may be inflicted, there are three 
elements of danger: hemorrhage, asphyxia, and infection. These 
are the factors which will determine the line of treatment, and without 
some urgent indication from one of these sources the treatment must 
be conservative. There are many things which stand in the way of 
radical procedures such as are employed in the case of abdominal 
wounds. In the first place, the operative technique is difficult; there 
is a marked disturbance of respiration following free access of air to 
the pleural cavity; the exact location of the lung lesion cannot often 



94 WOUNDS OF SPECIAL REGIONS. 

be determined; and finally, there is always, as Lejars remarks, so much 
guesswork in the prognosis, that we are constrained to give the patient 
the benefit of the doubt and leave the case to take its natural course. 

It is best to proceed in this wdse: If the case is seen from the first, 
supervise the transportation. Too much importance cannot be at- 
tached to the dangers of rough handling. As has been said elsewhere, 
the nearest shelter is the best. Cut away the clothing, scrub the skin 
adjacent to the wound and wash out the wound itself with alcohol or 
sterile salt solution. If on opening the lips of the wound, a bleeding 
point is seen, catch it up and ligate. 

If there is oozing from the depths, it is best to disregard it for the 
present. This constitutes the primary intervention except for suture 
of the wound, w^hich follows. 

Apply a dressing of sterile gauze, plain or soaked in collodion. 
Cover this with a layer of absorbent cotton and apply a firm bandage 
encircling the whole chest. Place the p«,tient on his back with the head 
and shoulders slightly elevated. Absolutely prohibit conversation 
and movement of any kind, and in the meantime keep the patient under 
close surveillance. 

In general terms, then, the treatment of any ordinary open wound of 
the chest involving the lung and pleura is to be summed up in two 
words, immediate occlusion and immobilization. 

But there are conditions which demand immediate intervention. 
These are acute anemia or asphyxia which may follow hemorrhage, 
external or internal; and hernia of the lung. 

External hemorrhage may follow^ any extensive wound of the chest 
wall, welling up from its depths or flowing by spurts during expiration. 
If there is no hemoptysis, it may be inferred that the lung is not 
wounded, but, in any event, the first treatment must be directed toward 
the intercostals and internal mamm_ary. It may be that a temporary 
hemostasis will be necessary and the tamponade described on page 
56, wall be indicated. 

The definite hemostasis requires a free enlargement of the wound. 
If pressure made against the lower border of the rib by an aseptic 
finger introduced through the enlarged wound causes cessation of 
hemorrhage, it is certain that it is an intercostal artery that is at fault. 



WOUNDS OF PLEURA AND LUNG. 95 

It may be difl&cult to clamp; it may be necessary to resect a rib, or to 
detach the periosteum, which will carry the artery with it. Through 
these tissues an inclusive ligature may be passed and the artery thus 
controlled. The internal mammary may require ligation above and 
below the wound. 

Internal hemorrhage is in every way more serious, for to the anemia 
is added the asphyxia which follows the compression of the lung. 

The patient is pale, anxious, with cold extremities, weak pulse 
and sighing respiration; the chest wall bulges; the normal resonance 
and vesicular murmur are altered; in short there are all the indications 
for an increasing hemothorax or hemo-pneumothorax. 

But even in the presence of these grave symptoms, it is by no means 
always indicated to operate. One must be content to repair the wound; 
occlude and immobilize; and wait awhile. 

But when the wound is followed by an immediate and complete 
hemothorax, or when the symptoms and signs point to a rapidly ap- 
proaching fatality, one must stand by with folded hands and see the 
end come, or operate, for there is nothing else of any use. An urgent 
thoracotomy must be done. 

Hernia of the lung is rare. The tumor is of variable size and is at 
first crepitant, but rapidly darkens and becomes hepatized. 

The indications for treatment depend upon the time which has 
elapsed and upon the condition of the tumor. If the wound is recent 
and the lung intact, the hernia must be reduced. Begin by a careful 
disinfection of the wound. Cover the tumor with an aseptic compress 
and tuck its edges under the whole circumference of the wound. A 
steady pressure over the central portion of the tumor will expel the 
air little by little, and, by reducing its volume, favor the reduction of 
the tumor. 

The compress is to be left until the skin wound is partially sutured, 
since by that means one may prevent the sudden pneumothorax which 
sometimes follows reduction. 

If the lung has been wounded, it must be repaired by suture, or by 
ligation and resection before being reduced. 

If some time has elapsed, it is as unsafe to reduce it as to reduce 
a doubtful herniated gut. 



96 WOUNDS OF SPECIAL REGIONS. 

Lejars insists upon resection with the thermocautery. Around the 
base of the tumor pass a ligature threaded on a blunt needle. By 
tying the ligature, a pedicle is formed which is to be amputated with 
the thermo-cautery. The stump is carefully disinfected and reduced, 
the chest wall repaired, and drainage instituted. 

Finally in the case where the tumor is already gangrenous and slough- 
ing, it is necessary to limit the treatment to antisepsis, leaving the 
slough to detach itself, and happily a cure may follow such spontaneous 
amputation. 

B. WOUNDS AT THE BASE OF THE THORAX. 

Wounds at the base of the thorax require a separate consideration 
for the reason that both the thoracic and abdominal cavities may be 
involved through wounds of the diaphragm. 

It must be remembered that the diaphragm corresponds to the level 
of the fifth rib in the right nipple line, and to the level of the sixth rib 
in the left. 

In stab or gunshot wounds, the lung on the one hand, and the 
stomach, intestine, spleen and liver on the other, maybe wounded simul- 
taneously, so that, compared with the thoracic wounds just considered, 
those at the base are much more complicated with respect to prognosis, 
diagnosis, and treatment. 

Ludlow, of Cleveland (Annals of Surgery, June, 1905), reports a case 
which illustrates this subject and exemplifies the treatment in general. 

The patient had received two stab wounds in the left side, inflicted 
with a candy maker's knife which had two blades set in a heavy handle. 
One wound entered at the ninth interspace in the axillary line, and 
through it protruded omentum. The blade had entered the chest 
wall obliquely and the skin acted as a valve, but when the skin was 
retracted, the air rushed in and out of the pleural cavity with each 
respiration. The hemorrhage from the wound was slight. 

The second wound was situated directly below the first in the elev- 
enth interspace. Omentum protruded from this wound also, and the 
bleeding was slow but apparently increasing. 

Oi)eration. — Ether anesthesia; a careful cleansing of the field. A 



WOUNDS AT THE BASE OF THE THORAX. 97 

digital examination revealed the fact that the upper wound, traversing 
the pleural cavity without injury to the lung, had perforated the dia- 
phragm. The finger passed through these wounds, met the finger of 
the other hand passed through the lower wound, in the abdominal cavity. 

The lower wound was enlarged, revealing an active hemorrhage from 
the spleen. The cut surface of the spleen was pulled into the wound 
and a spurting artery clamped. The splenic wound was four centi- 
meters in length and extended almost through the substance of the 
organ. 

The cut surfaces were brought into apposition by mattress sutures 
of plain catgut No. 2, on a curved round needle. This controlled the 
hemorrhage. Neither by palpation or inspection could any wound of 
the stomach or intestines be found. The diaphragm was then repaired 
with chromic gut No. 3. The operation was accomplished without the 
resection of a rib. A small cigarette drain was left in both wounds and 
the external wounds sutured. The week following the operation there 
was some discharge of blood and debris, but no active hemorrhage. 
The recovery was uneventful and complete. 

These wounds at the base of the thorax involving the diaphragm, 
will nearly always present an omental hernia. It is often necessary, 
after enlarging the thoracic wound by resecting a rib or forming a costal 
flap, to resect the protruding omentum, and at the moment of reduction 
of the stump, one may have an unobstructed view of the wound in the 
diaphragm. If blood oozes from it, there is abundant evidence of a 
wound of an abdominal viscus. If there is no bleeding, introduce a 
finger through the opening in the diaphragm and examine the stomach 
and adjacent structures. If no injury is found, and the examining 
finger is not covered with blood, proceed at once to repair the dia- 
phragm. 

A curved needle is best, and interrupted sutures. If there are 
wounds of the abdominal viscera, they may possibly be repaired through 
the phrenic wound, and, in fact, if at all possible, it is the method of 
election. By this route one may readily reach the convex surface of 
the liver or the left end of the stomach. 

Still, if the exploration is difficult, if the bleeding is abundant, it is 
better to lose no time but to do a median laparotomy at once, gaining 
7 



98 WOUNDS -OE SPECIAL REGIONS. 

additional room, if necessary, by a transverse incision, following the 
costal arch. Subsequently the wound in the diaphragm may be re- 
paired through the thoracic opening. 

Wounds of the diaphram of whatever form, perforations, or rup- 
tures due to crushing injuries to the chest, are likely to be the site of 
hernias. 

Especially in the latter class of injuries, must one be on his guard 
for this injury. Sometimes there are certain signs which point at 
once to the presence of a diaphragmatic hernia, the displacement of 
the heart, the bulging of the lower intercostal spaces, and the presence 
on auscultation of sounds which, in no way, resemble the vesicular 
murmur. In these cases, it is best to open up the eighth intercostal 
space and resect the ninth rib, which will usually give a free access 
to the site of injury. 

C. WOUNDS OF THE PERICARDIUM AND HEART. 

Not every precordial wound though penetrating the chest reaches 
the heart. Such a wound may be followed only by a slight emphysema, 
or other insignificant symptoms. Such wounds are to be treated by 
aseptic occlusion and "expectancy." 

If the heart is wounded, death is usually so rapid that no measure 
of relief can be considered. Still a wound of the heart is not to be con- 
sidered as inevitably fatal and beyond surgical skill. The mortality 
varies with the character of the wound and its location. Injury to 
the auricles is more fatal than that of the ventricles, and injury of the 
pericardium much less serious than if the heart is involved. 

The number of reported cases saved by timely intervention is con- 
stantly increasing, and will increase all the more rapidly as time goes by. 

The indications for intervention spring from the hemorrhage, which 
may be internal, external, or both. If external, it spurts from the 
wound or wells up continuously, uncontrolled by occlusion or com- 
pression. If internal, it may be the pericardium in which it accumu- 
lates, and there are the symptoms of hemo-pericardium. Added to 
the physical signs, there are the symptoms due to interference with the 
heart's action; the pulse is miserably weak and rapid, and the oppres- 



INJURIES TO THE ABDOMEN. 99 

sion, the cyanosis and venous gorgement, all bear witness to the com- 
pression of the auricles. The apex beat is lost, the heart sounds muf- 
fled, the precordial dullness augmented, and the thoracic wall 
bulged. 

Again, the pleura may be opened up at the same time and offer a 
receptacle to the blood, so that symptoms scarcely less urgent arise 
from the hemothorax. 

From these symptoms arise the indications for operation. When 
they are present it is imposed to open the pericardium, relieve the heart 
and repair its wound. 

But however urgent may be the indications, one must not entirely 
overlook the proper aseptic preparations; for even though the operation 
be successful, death may come later from septic infection if the field 
was not prepared. (See page 383, Repair of Pericardium and Heart.) 

INJURIES TO THE ABDOMEN. 

I. Contusions. 

II. Wounds. 

I. Contusions of the abdomen occur in many ways; they may be 
the result of severe blows, the kick of a horse, from falls, or from the 
crush of heavy wheels of vehicles. The gravity of such an injury is 
proportionate to the amount of visceral injury, but this is often not 
apparent from the first. 

Whether the viscera are injured or not, there is always some degree 
of shock. In the first hours following the injury, in the doubtful cases, 
the therapeusis must be limited to the treatment of shock. If trans- 
portation is necessary, it must be done with the greatest care. 

Once the patient is placed in bed, his clothing must be removed, 
his head lowered, the extremities kept warm, and repeated injections 
of normal salt solution or adrenalin made, as the character of the shock 
indicates. 

In the meantime, the case is to be studied and it is to be decided 
whether or not there is a rupture of an organ, or other source of hemor- 
rhage. 

The responsibility is a heavy one, for an internal injury overlooked 



lOO AVOUNDS OF SPECIAL REGIONS. 

or discovered too late, is likely to result in death. The patient may 
rapidly recover from the shock, but this by no means proves the absence 
of a visceral hurt. 

In the typical case of grave injury, the symptoms of shock are only 
temporarily relieved by the injections; rather, they are shortly replaced 
by those of internal hemorrhage. The pulse remains small and fre- 
quent, the skin cold, the face anxious and drawn. The abdomen is 
distended and tender to the least pressure, especially in the zone of 
direct injury. There is dullness in the flanks. There is no escape of 
gas from the bowels, or passage of urine. The patient is restless and 
frequently sighs, and seems to realize his impending fate. 

In such a case, the indications are plain. There can be no ex- 
cuse for delay, for awaiting the signs that can only be those of beginning 
peritonitis. Prepare for an immediate laparotomy. 

But suppose the case is not accompanied by the typical symptoms. 
How shall we determine in two or three hours whether or not there is 
a grave lesion ? A conclusion must be reached from the study of two 
fractors: (a) the pulse, and (b) abdominal tension. 

(a) The pulse, disturbed at first by the shock, rapidly approaches 
the normal perhaps, but within a half hour or sooner, it can be deter- 
mined that it is getting weaker and more rapid. Such a change is 
particularly indicative of hemorrhage. If there is any discrepancy 
between the pulse and temperature, Lejars insists that the former is 
the safer guide, for a subnormal temperature resulting from shock 
may persist long after the other symptoms have disappeared. 

(b) The abdomen may or may not be swollen, but over the site of 
the injury the abdominal muscles soon begin to grow rigid and resent 
the least touch, under which they may be felt to contract and stiifen. 
This rigidity, localized at first, tends to spread and include the entire 
abdomen. 

The tension is usually augmented by progressive meteorism. If one 
has attentively observed the case, it will be seen that it, also, is at first 
localized but rapidly becomes general. 

Dullness in the flanks is a valualDle sign when present, but its absence 
settles nothing. It may be masked by the distended stomach and in- 
testine; again the blood may not collect in the iliac fossa, but may flow 



WOUNDS OF THE ABDOMEN. lOI 

directly into the pelvic cavity especially if the hemorrhage is on the 
left side of the mesentery. 

These modifications of pulse and temperature, of abdominal tender- 
ness and tension, must be taken as sufficient indication for urgent in- 
tervention, for the prognosis does not, in reality, depend more upon 
the nature and m.ultiplicity of the visceral lesions than upon the time 
of intervention, for every hour of delay adds to the chances of infection 
and sepsis — elements wich the early operation may practically elim- 
inate. 

Another eventuality: The case is not seen until infection has 
fixed itself upon the peritoneum; the pulse is weak and rapid and pro- 
gressively growing worse; the temperature is subnormal, the extremi- 
ties cold; a marked tympanites with persistent vomiting perhaps comes 
on. 

Then indeed, it is late to operate — especially when that means a long 
and tedious laparotomy. Every doctor must answer for himself the 
question, "Is it too late 2^'' As Lejars says, we must extend as far 
as possible the Hmits of intervention in such cases, for it is the last 
resource, and even though the mortality is very great, the occasional 
unexpected recovery legitimizes the operation. (See laparotomy for 
traumatism, page 417.) 

II. Wounds of the Abdomen. — Clinically, these fall into two groups, 
(a) those in which there is doubtful perforation of the peritoneum, 
and (b) those in which perforation of the peritoneum is quite 
obvious. 

(a) The patient presents himself with a wound of the abdominal 
parietes, of doubtful depth. It is easy to determine once for all 
whether the peritoneum has been perforated (and upon that the 
prognosis depends) by passing a probe or grooved director. But one 
should certainly do nothing of the kind. There is a definite mode of 
examination to which one must rigidly adhere. 

Begin by a hurried inquiry into the circumstances of the injury, 
and the character of the weapon. Disinfect the hands for an operation. 
Finally scrub and disinfect the abdominal walls. Not until this is 
completed, is the wound ready to be examined. 

Carefully separate the lips of the wound with finger or retractors 



I02 WOUNDS OF SPECIAL REGIONS. 

and as you proceed, carefully wipe each layer as it is exposed. If 
necessary to facilitate inspection, enlarge the wound; this will often 
be the case, especially where the vulnerating instrument has entered 
obliquely. 

Exposing the various layers, the peritoneum is found intact: there 
is no oozing from below the level of the muscular layers, and if this 
finding accords wdth the other signs observed, you may conclude at 
once that the w^ound is non-penetrating. In such a case, carefully 
cleanse the wound and repair each layer separately by continuous suture 
with catgut; the skin with silk or silkwormgut; cover with sterile gauze, 
a thick layer of absorbent cotton, and a firm abdominal binder, and 
thus have been taken the best steps to prevent infection or ventral 
hernia, which is often the result of these wounds. 

If the wound is penetrating, the mode of procedure depends upon 
whether it is a (a) narrow, or (b) a large incised wound. 

(a) A stab w^ound is the type — a thrust from a knife, dagger, or 
bayonet. There may be persistent oozing of blood alone, or blood 
mixed with bile and urine, or "food products." Such a mixture is 
pathognomonic of visceral injury, but nothing can be decided from 
its absence. 

The persistent hemorrhage is strongly suggestive of serious injury 
to an organ, especially where it coexists wdth a fading pulse, pallor, 
tympanites, and rigidity and tenderness of the belly wall; yet the ab- 
sence of all these signs gives no assurence of the absence of a visceral 
injury. 

In any event, then, an exploratory laparotomy is indicated, for only 
by that means can one assure himself of the conditions. Ordinarily 
the wound itself is enlarged for the purpose of exploration, but in the 
case of more than one wound, or w^hen the abdominal walls are 
very thick, it may be advantageous to resort at once to median 
laparotomy. In either case, the abdominal opening should be large 
enough for rapid work. If the laparotomy is done at the site of the-in- 
jury, it will be wise to disarrange the viscera as little as possible, 
when sponging out the exudates. Carefully inspect whatever parts 
present, and often the lesion will be revealed by this first search.. 

If a median laparotomy is done, as soon as the cavity is opened. 



INCISED WOUNDS OF THE ABDOMEN. I03 

proceed to the site of the injury; cover the adjacent coils of intestine 
with compresses, thus preventing their possible infection. 

The lesions are only rarely multiple or difficult of repair in this class 
of abdominal injuries. 

(b) Extensive Incised Wounds. — These wounds are produced by in- 
struments with a long cutting edge, or by the ripping cut of small 
knives. Horned animals occasionally produce them. 

The chief characteristic of these wounds, is eventration^ always 
present in some degree. If the case is seen immediately, the mode of 
procedure is very definite. But only too often the patient's efforts have 
augmented the hernia, or he or his friends have made untimely 
attempts to reduce it. 

Having cleansed the hands and the abdominal walls in the usual 
way, begin next a systematic cleansing of the eventrated mass. Cleanse 
it with warm sterile water, or normal salt solution, rubbing gently with 
the fingers, every inch of the projecting bowel or omentum. Only 
in the thoroughness of this step, is there any assurance of success. If 
any visceral wounds are discovered in the cleansing process, they are 
to be repaired at this time. 

Once the cleansing and repair are complete, proceed to reduce 
the hernia. The wound may need to be enlarged; if this is necessary, 
slip a finger under an angle of the wound to serve as a guide, and divide 
the tissues with scissors. The other angle may be treated in the same 
way. Catch up the peritoneum with forceps along the whole length 
of each side of the wound. Now lift on the forceps, and in this way 
create a sort of funnel with smooth sides over which the bowel readily 
glides in reduction. 

Do not attempt to reduce by rough pressure, which may contuse the 
bowel. If "taxis" fails, there is a method which will surely succeed. 

Spread a large compress over the mass; tuck its edges well under 
the entire circumference of the wound, and with both hands, make a 
gradual pressure on the mass enveloped in the compress, coaxing the 
refractory loops into place with the fingers and at the same time pushing 
the compress further under the abdominal walls. The assistant, in the 
meantime, lifts up on the forceps attached to the peritoneum, raising 
the abdominal walls as the hernia recedes. 



I04 WOUNDS OF SPECIAL REGIONS- 

When the reduction is complete, leave the compress in place, secured 
by forceps until repair of the peritoneum is nearly complete. Repair 
the abdominal wall: begin by suture of the peritoneum with small 
catgut. If the tension is great, it may be necessary to include the mus- 
cular plane in the suture. Next repair the muscular layers separately 
by continuous catgut suture; in the same manner, the aponeurosis, and 
finally the skin, with interrupted silkwormgut sutures. 

Drainage is a question which always arises, but Lejars assures us 
that if the cleansing is carefully carried out, drainage is in no wise 
necessary. // the case is seen late, but there exist only a few soft adhe- 
sions between the bowel and the walls of the wound, the same disinfec- 
tion is carried out, the adhesions around the orifice gently broken up, 
and the mass reduced, as before. Drainage is quite indispensable if 
there are already the signs of a beginning peritonitis. 

If the mass has become the site of a purulent peritonitis, the coils ag- 
glutinated by false membrane, and gangrenous, there is nothing to do 
except to keep applied moist antiseptic compresses, which must be 
frequently renewed. If the patient survives, whatever intervention is 
needed, may be undertaken later. 

• WOUNDS OF THE VULVA AND VAGINA. 

The chief danger in wounds of these parts is hemorrhage, especially 
when the vulva is involved and its venous plexuses torn. These 
wounds may be contused, lacerated or punctured, and more frequently 
occur from falls astride some object, and by that means the bulb of the 
vagina is crushed against the ramus of the pubes. 

Forcipressure and ligation may be ineffectual to control the bleeding 
and often the only recourse is tamponade, first disinfecting the wound 
and the region adjacent, and afterwards applying a T bandage and 
bringing the thighs firmly together. 

Perforating wounds of the vagina call for a most careful examination, 
for not only may the vaginal walls be involved but the rectum, bladder, 
or peritoneum as well. Careful suturing is here the best means of 
controlling hemorrhage. Peritonitis may result from such injuries, 
or more remotely, fistulae or atresia of the vagina. 



WOUNDS OF THE SCROTUM. I05 

Any serious hemorrhage following coitus calls for an examination. 
It may ensue from a tear of the hymen, or of the posterior wall of the 
vagina. Cases are on record in which the tear penetrated the rectum. 

Deep suturing serves at the same time to control hemorrhage and to 
promote repair. 

WOUNDS OF THE PENIS, SCROTUM AND TESTICLE. 

The penis may be fractured and if the urethra is not involved the 
hemorrhage will be subcutaneous. Unless the extravasation is very 
large and progressive there is nothing to do but to bandage the organ 
and put the patient at rest. Otherwise it will be necessary to expose 



Fig. 74. — Suture of wound of testicle. A, beginning its repair; B, wound in 
testicles repaired. C, tunica vaginalis; (Lejars.) 

and suture the break in the corpus cavernosum. But with such a pro- 
cedure one may expect a severe hemorrhage. Open wounds of the 
erectile tissues of the corpora cavernosa or corpus spongiosum may be 
expected to bleed freely. It is usually advisable to pass a sound to 
determine the integrity of the urethra, suturing it first, if involved, and 
then carefully coapting the erectile tissues. 

In the case of wounds of the scrotum merely the integuments may 
be penetrated, or more deeply the tunica vaginalis or the testicle as 
well. It must be remembered that any considerable wounding of the 
tunica of the testicle may result in hernia of the parenchyma. 



io6 



WOUNDS OF SPECIAL REGIONS. 



The scrotal tissues must not be roughly handled in cleansing, and 
the sutures must not be too tight, for there is a tendency to edema and 
sloughing. The repair of these various structures must be conducted 
separately. 

If the tunica vaginalis is opened up and the testicle herniated, it 
must be carefully cleansed and returned and the tunica sutured, with 
or without drainage, depending upon the probabilities of infection. If 
the tunica be destroyed and the testicle remains sound, it must be pre- 




*l-n;JE 



Fig. 75. — Emergency castration. A, transfixion of the cord and ligature of 
one-half. B, ligature carried around the entire cord. (Lejars.) 

served, covering it as much as possible with such of the serous covering 
as remains. Incised wounds of the testicle call for suturing of the 
fibrous coat with catgut. 

The tunica vaginalis is next repaired with a continuous suture (Fig. 
74), and finally the scrotum. 

If the testicle is lacerated, or if seen late and manifestly infected, 
it must be removed without delay. Expose the spermatic cord as 
high up as possible, and at that level ligate the various elements separ- 



WOUNDS OF RECTUM. I07 

ately and firmly, and resect. Trim away any infected tissues in the 
scrotum and repair, making drainage (Fig. 75). 

Cotton, of Boston (Amer. Jour. Urol., Nov., 1906;, describes a case 
of injury to the testicle resulting from a blow on the scrotum by a batted 
base-ball. Shock and excruciating pain ensued, gradually subsiding 
coincident with the development of a large scrotal hematoma. 

Operation. The superficial tissues were infiltrated with blood. A 
rent an inch long in the tunica vaginalis. Bleeding from the sper- 
matic artery. The tunica albuginea was torn in shreds, the parenchyma 
destroyed. " The testis had evidently exploded under the swift impact 
as a full bladder bursts under a blow." After removal of clots and 
irrigation the tissues were sewed up layer by layer with catgut and 
without drainage and light pressure applied. Convalescence un- 
eventful. 

WOUNDS OF THE RECTUM. 

Wounds of the rectum are rare. They are usually punctured wounds, 
due to falling upon pointed objects, gunshot wounds, or tears accom- 
panying fractures of the pelvis. The chief dangers are hemorrhage 
and infection. 

Wounds of this region are usually self-evident, though their extent 
may be a matter of doubt, so that every such injury demands a care- 
ful examination. The examination calls for inspection. To depend 
upon touch alone may lead one into grave error. 

In every serious injury of this character anesthetize the patient, 
dilate the anus, and by the use of retractors expose the wound. Douche 
with hot normal salt solution. If the hemorrhage persists, the bleed- 
ing points are to be clamped with long forceps and an attempt made 
to suture en masse, for at that depth it will be hardly possible to ligate 
the vessels. Sometimes in lacerated wounds, the oozing can be con- 
trolled only by tamponing the rectum firmly, packing around a large 
tube in the center. 

Suturing these wounds is not so desirable as one might at first think, 
for the sutures may conduct sepsis to the deeper tissues. Do not suture, 
then, unless the wound is easily accessible, recent and clean. If the 



Io8 WOUNDS OF SPECIAL REGIONS. 

sutures are used, frequent irrigations must be employed and the 
bowels kept quiescent for several days. 

If the rectal wound has penetrated the peritoneal cavity, ^vhich fact 
may develop in course of the examination or may be suspected from 
the tympanites and tenderness of the abdomen, the better plan is to 
proceed to a laparotomy. 

The abdomen is to be opened in the middle line, the patient put in 
the Trendelenburg position, the pelvis cleansed, and the wounds re- 
paired by two tiers of sutures. 

If the small intestine should become herniated through a rectal tear, 
laparotomy is again indicated, reducing the hernia by traction from 
above. If the herniated loop protruding from the anus be gangrenous, 
in order to avoid infection of the peritoneum the affected segment 
should be resected and the two ends temporarily ligated before pro- 
ceeding to the laparotomy. Once the abdomen is opened, the two 
ends of the bowel are to be pulled up and anastomosed. 



CHAPTER XL 

GUNSHOT AND OTHER WOUNDS IN MILITARY 
PRACTICE.* 

Gunshot wounds are essentially contused, punctured or lacerated 
wounds, or combinations of all of these, differing from wounds pro- 
duced by other means only in their potentialities. 

If the gunshot wounds of military service differ from those seen in 
civil practice with respect to their character, prognosis, and treatment, 
it is because the bullets in each case differ with respect to hardness, 
initial velocity and range, and because the wounds are produced in 
different environments. 

The modern army bullet (Fig. 76) is of small caliber, is jacketed 
with steel, has a very high initial velocity, and long range. At close 
range, such a missile is tremendously destructive to all the tissues alike, 
producing the conditions of crushed or lacerated wounds. 

On the skin at medium or long range, the wound of entrance is 
small, less than the diameter of the ball; likely to be dirty. The wound 
of exit is larger, more irregular and bleeds more freely (Fig. 77). 

The pain in skin wounds is often moderate, usually a burning sensa- 
tion, and the shock not severe. 

The fascia presents a smaller opening than the skin, the fibers being 
split, rather than cut in twain, and for this reason the wound tends to 
close, oftentimes materially interfering with drainage. The muscles 
are contused, lacerated, and are likely to be infiltrated. 

The tendons are quite likely to be pushed out of the way and not 
wounded. At other times, they are partly or wholly divided. 

The hlood vessels may be pushed aside, but more frequently are more 
or less torn, and one of the frequent causes of immediate death is hemor- 

* Authorities specially consulted: Makins, Stevenson, Senn, Von Bergman, 
Fischer, Havard, De Wreden, Osuki, and various contributions to the Jour. Assn. 
Military Surg. 

109 



no GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 

rhage. Yet even in the case of laceration of large arteries, there may 
be spontaneous hemostasis. 

Aneurism (Fig. 78) is the common sequel if the artery is grazed or 
contused, requiring double ligation and excision. 




Martini-Henry. 



Fig. 76. — Types of cartridges. (Makins.) 

Guedes. Lee-Metford. Mauser. Krag-Jorgensen. 



When not pushed aside, the nerves may be contused or divided, re- 
sulting in paralysis — immediate or remote — neuralgias, or trophic 
disturbances, such as wasting or contracture of muscles, or blanching 
of the skin, corresponding to the distribution of the nerve. Even though 
the nerve itself is not injured, these conditions may result- from its 



CHARACTER OF BONE LESION. 



Ill 



inclusion in scar tissue. It is often indicated to expose the nerve and 
clear it of e.^udates or to attempt suture (see repair of neves). 

Bone presents a wide variation in the character of the lesions pro- 
duced. There may be mere puncture, there may be extensive com- 
minution, and any grade of injury between these two extremes (Fig. 79). 




Fig. 77. — Showing small entrance wound, and large irregular wound of exit. (Makins.) 



The character of the injury will depend upon two factors: the 
character of the bone and the range of the bullet. 

(A) If the bone is soft and cancellous, the tendency is toward per- 
foration; if it is hard and compact, the tendency is toward cohiminution. 

The articular end of the long bones, the short, and the irregular 



112 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 



bones are likely to be merely perforated. On the other hand, the 
shaft of the long bones, the skull, the scapula, are much "more likely 
to be shattered. 

(B) At long range, perforation is rather to be expected; at very 
close range, comminution is the rule. 

So far as the long bones are concerned, transverse fracture rarely 
occurs, and if longitudinal fracture occurs, its 
tendency is to stop short of the articulation 
(Fig. 80). 

With respect to the bones of the limbs, it is 
to be noted that the exit wound will be the 
more comminuted (Fig. 81). Perforating 
fractures without solution of continuity, are 
often difficult of diagnosis, because of the 
absence of characteristic symptoms. The 
diagnosis is to be made by reference to the 
track of the bullet, palpation, bone dust in the 
wound of exit, etc. (Fig. 82). 

Comminuted fractures present an excessive 
mobility, and often crepitus is hard to elicit. 
Owing to "local shock" the limb may be quite 
powerless and yet painless. 

Primary shortening is often absent by reason 
of the muscular relaxation due to shock. Even 
though healing takes place uneventfully, a large 
amount of callus is likely to be thrown out and 
for a long time, the union will not be strong. 

Acute osteo-myelitis may follow infection. On the other hand, 
necrosis may occur late and after the wound has apparently quite 
closed. 

In the bones of the skull is frequently seen the so-called "gutter 
fracture" in which there are usually two apertures in the scalp, con- 
nected by a trench ploughed through the outer table and diploe. 
(Figs. 83, 84). 

The corresponding part of the inner table is comminuted exten- 
sively and perhaps depressed. 




Fig. 78. — Traumatic 
aneurism (Mouliin.) 



TYPES OF GUNSHOT FRACTURE. 



113 



The length of the gutter depends upon the surface curvature, and the 
antero-posterior are more serious as a rule than the transverse (Fig. 85). 





Fig. 79.^ — Types of fracture of long bones. (Makins.) 
A, primary lines ot stellate fracture. B, stellate on one side, transverse on the other. 
C, complete wedge isroken out. D, incomplete wedge. E, oblique fracture. 

The joints present effects peculiarly variant; the capsule alone may 
be injured; the articular ends of the bones may be guttered or pene- 




FlG. 



-Lower end of femur, showing tendency of fissures to 
stop short of articular ends. (Makins.) 



trated with or without injury to the capsule; there may be much 
shattering, fissures radiating in all directions; or the joint may be in- 
8 



114 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 

volved by extension from the wound of the shaft. The bullet may be 
retained in the joint cavity. Effusion into the joint is a constant 
symptom following perforation, a mixture of blood and synovial fluid. 

Of the great cavities and viscera, each has its own particular symp- 
tomatology. 

The cranium, according to Von Bergman, presents the following 




Fig. 8i. — Small wound of entrance and large wound of exit of left leg. Frag- 
ments of bone carried to right leg producing large irregular wound requiring 
amputation. (Makins.) 

lesions: at short range, the skull and scalp are torn to pieces; at i6o 
feet, the scalp is preserved but the skull is shattered; there are two 
openings with lacerated edges with brain exudate, the wound exit 
always larger than that of entrance. 

At 320 feet, there are two openings, each surrounded by a series of 
concentric fissures in addition to radiating fissures (Fig. 86 j. 



GUNSHOT FRACTURE. 



115 




Fig. 82. — Oblique perforation implicating 
both epiphysis and diaphysis, with large frag- 
ment at exit. (Mikins.) 




Fig. 83. — Transverse section of "gutter" fracture. (Makins.) 
A, no loss of substance. B, Comminution. 



ii6 



GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 



At 4000 feet, the radiating fissures still appear. 

At 5600 feet, entrance and exit wounds are clean cut holes. 

At 8000 feet, there is only the wound of entrance, and the bullet 
lodges in the brain. De Wveden, of the Russian Army, says that only 
beyond a range of 120G steps, did the Japanese bullet perforate so as 
to permit of recovery. The injuries to the dura mater are analogous 
to those of the skull. 





^- 




Fig. 84. — Gutter fracture perforating skull in the center of its course. (Makins.) 



The hrain itself, semifluid, is torn to pieces at short range, through 
hydrodynamic action. At long range, the bullet merely traverses 
the brain, producing areas of contusion in the, neighborhood of its 
track. There may be a diffuse hemorrhage throughout the brain, the 
ventricles being filled with blood. 

The symptoms are such as belong to concussion, compression, con- 
tusion or laceration in general. 



GUNSHOT FRACTURE OF SHELL. 11^ 

'' The vast majority of gunshot fractures of the skull are accompan- 
ied by more or less marked symptoms of brain injury: paresis of 
certain groups of muscles; paralysis, motor and sensory; loss or im- 
pairment of special senses, usually sight or hearing; Jacksonian epilepsy; 
twitching and contraction of certain muscles; signs of brain irritation, 
due to injury of the cortex — in fact, all the symptoms of brain damage, 
in all their varying combinations. Usually the symptoms are in corre- 
spondence with those to be expected in consequence of injury to the 
brain cells evidently implicated, but occasionally symptoms arise 




Fig. 85. — Superficial perforating fracture; roof lifted at both openings. (Makins.) 

which are not to be accounted for by such direct inference; they must 
be due to injury to outlying portions of the brain, produced by vibration 
or wave action, communicated to the comparatively fluid brain by 
the passage of the bullet." (Stevenson, Report from South African 
War.) 

The spine is seriously injured in proportion as the cord suffers. 
Aside from the cases in which the cord lies in the track of the bullet 
and is partially or completely divided transversely (Fig. 87), there 
are those cases in which there is no anatomical lesion of the cord, per- 
haps nothing more than perforation of a vertebra, yet the functions of 
the cord are markedly depressed. This is ''concussion'' of the cord, 



Il8 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 

which Makins (Surgical Experiences in South Africa) describes in 
detail. 

The degree of concussion, and therefore the degree of functional 
depression, depends directly upon the velocity of the ball. 

In slight spinal concussion, the symptoms consist in loss of cuta- 
neous sensibility, motor paralysis, and vesical and rectal incompetence, 
persisting for a few hours or even two or three days. 







Fig. 86. — Extensively comminuted gunshot fracture of the skull. 
(Senn after von Bergmann.) 

Recovery begins with return of sensation, often modified, followed 
later by return of motor activity. 

"Severe concussion, contusion or medullary hemorrhage, may be 
considered as lesions of equal degree as to severity, bad prognosis and 
unsuitability for active interference; all characterized by the same 
essential phenomena, viz.: symmetrical abolition of sensation and 
motility, absence of any sign of irritation in the paralyzed area, and 



GUNSHOT WOUNDS OF THE SPINE. 



119 



loss of patellar reflex. These severe injuries are all accompanied by 
profound shock. The patient lies still, with eyes closed, great pallor 
of surface, the sensorium benumbed, the pulse small and irregular, 
respiration shallow" (Makins). 

In addition to these lesions, there are such as arise from compression, 
either of bone or from a lodged bullet. But as Makins says, it may be 
assumed that a bullet injuring the vertebra sufficiently to displace 
bone, has, at the same time, produced grave lesions of the cord. If 




Fig. 87. — Complete division of spinal cord; bullet retained. 



the pressure is due to the bullet, it argues that its velocity was low 
and that there may be no serious lesion of the cord and that the symp- 
toms are those of compression alone. Compression due to extra-dural 
hemorrhage can rarely produce serious symptoms. 

The chief surgeon of the Russian Army in the Manchurian cam- 
paign confirms the notion previously held as to the great gravity of 
wounds of the spine. 

The thorax may or may not be penetrated by the impact of a bullet, 
though penetration, of course, is the rule, and these wounds constitute 
a large part of the casualties of battle. The non-pcnctrating wounds 



I20 GUNSHOT AND OTHER WOUNDS IN MILITARY PARCTICE. 

present no features of especial interest. The skin and muscles may- 
be injured in various degrees between simple perforation and serious 
laceration. 

The clavicle and scapula may be fractured; the axillary space may 
be involved, with serious results. The penetrating w^ounds cross the 
thorax in every direction, transversely, longitudinally and obliquely. 

Those which traverse the thorax longitudinally, and are received 
while firing or advancing in the prone position, are noteworthy in 
that the abdominal cavity is usually also involved. 

The abdominal cavity is also likely to be penetrated when the base 
of the thorax is crossed. 

If a rib is involved, the bone injury is usually limited and these 
fractures are considered of importance only when the intercostal ar- 
tery is wounded. In many of these fractures from the army bullet, 
the ordinary symptoms are absent, either because of the localized char- 
acter of the injury and absence of contusion of the soft parts, or be- 
cause the fragmentation in the track of the bullet is so complete as to 
preclude crepitus. 

The lungs, almost certain to be involved in perforating wounds of 
the chest, escape with remarkably slight damage, owing to their elas- 
ticity. 

" In point of fact, there is no reason why a perforation by a small 
caliber bullet should be much more feared than a puncture by an ex- 
ploring trocar, and the danger of the two wounds is possibly very nearly 
the same" (Makins). 

Those which pass near the root of the lungs are very likely to involve 
the great vessels, followed by rapid and fatal internal hemorrhage. 

Certain symptoms manifest themselves in most cases of lung injury, 
in some degree. Shock, if it exists at all, is not usually serious and 
arises rather from the injury to the chest wall; nor are pain and dyspnea 
prominent. 

Colonel Havard, U. S. Military Attache, w^ith the Manchurian 
army, instances cases where soldiers walked twelve to eighteen miles 
after being shot through the lungs. 

Hemoptysis is fairly constant but not persistent longer than two or 
three days. Cough is seldom troublesome and pneumothorax is rare. 



PENETRATING WOUNDS OF THE ABDOMEN, 121 

Hemothorax is very frequent, but in the great majority of cases 
is due to hemorrhage from the chest walls — to the intercostals rather 
than to the lung injury (MaHns). 

The symptoms of a hemothorax reach their full height on the third 
or fourth day. The pain is severe, the pulse and temperature rise, 
dyspnea is prominent, respiratory movement on the affected side is an- 
nulled, and there are the physical signs of fluid in the pleura. 

The cause of the temperature is a matter of concern, for the fever 
suggests empyema. It seems always to rise pari passu, with the in- 
crease of blood in the pleural cavity, often declining after the third or 
fourth day, always falling after a paracentesis and rising anew with 
fresh access of pleural hemorrhage. 

The fever of infection arises later, persists, or gradually mounts 
higher. 

Perjorating wounds oj the heart in warfare, Makin regards as cer- 
tainly fatal, believing that the cause of death is not hemorrhage, but 
sudden stoppage of the heart action. 

Senn believes that death usually occurs from compression of the 
heart, due to hemorrhage within the pericardium. In those cases, 
where from the anatomical features, the heart would seem to be in- 
volved and yet presents no symptoms of injury, the inference must be 
that it escaped, owing to change in position and size, incident to con- 
traction. 

Colonel Havard (Journal Ass'n Mil. Surg.) writes of the Japanese 
bullet, that it has been known to pass through the heart without fatal 
effect. 

Penetrating wounds oj the abdomen are seldom simple in character 
for it only rarely happens that a single viscus is involved. The one 
symptom which, if it occurs at all, is common to wounds of all abdom- 
inal organs, is peritonitis. The sources of hemorrhage are numerous. 
The degree of injury to every organ decreases with increased range. 

The small intestine is naturally the structure most frequently wounded 
and, of course, its perforations are multiple (Eig. 88). 

Pain, collapse, vomiting and peritonitis are nearly always present, 
although present also in wounds of the stomach and large intestine. 

The peritonitis is more widespread in the case of the small intestine 



1:22 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 

than in the case of the stomach and large intestine, because of the 
greater activity and motility of the small intestine. Vomiting of blood 
may be taken to indicate perforation of the stomach. The stomach 




Fig. 88. — Perforating wounds of small intestine. A, entry. B, exit. 
Note slit-like character and eversion of mucous membrane; localized 
ecchymosis more abundant around exit aperture. (Makins. from St. 
Thomas hospital museum.) 



and intestines escape "explosive" effects in proportion as they are 
empty at the time of injury. 

The bladder, when wounded, may present two openings, both may be 
extra-peritoneal, both may be intra-peritoneal, or one may be intra- 
and the other extra-peritoneal. 



TREATMENT QY GUNSHOT WOUNDS. 1 23 

An extra-peritoneal wound bleeds the more profusely; an intra-perit- 
oneal wound permits the escape of urine into the peritoneal cavity. 

Hematuria, or suppressed urination with an empty bladder, points 
to the character of the injury. 

The liver is likely to be simply perforated or notched, though at 
close range, "explosive" effects are observed. The chief result is 
hemorrhage and, in some cases, an escape of bile, due to injury to the 
gall bladder or the bile ducts. 

The spleen, if merely perforated, gives rise to hemorrhage, usually 
insignificant, unless its main vessels are involved. 

The kidneys give rise to either extra- or intra-peritoneal hemorrhage, 
which is not serious unless the perforation involves the hilum. Shock 
is nearly always present as well as hematuria and frequent urination. 

The pancreas: there is no way by which injury to the pancreas may 
be diagnosed. It may be merely inferred from the cause of the bullet. 
It is so situated that it cannot be reached by a bullet without injury 
to other organs more likely to give due notice of their affront. 

Prognosis and Treatment. — Flesh wounds, uncomplicated, heal 
without difficulty. On the field of battle the first aid dressing is ap- 
plied, and in the simpler cases need not be disturbed. Ordinarily it 
will need to be changed at the field hospital. The wound is to be 
regarded as an aseptic one, unless the contrary is demonstrated, and 
treated as such. 

Soap and water as a means of sterilizing the skin cannot be so gener- 
ally used as in civil practice, on account of the difficulty of supplying 
sterile water in the midst of a campaign, so that antiseptic solutions 
must often suffice. 

If the bullet has lodged, under no circumstances is it to be probed 
for; although if its location is superficial, it may be removed at the 
time of the first dressing. 

The aim of the dressing is to secure antiseptic occlusion, and as 
much as possible, immobilization. 

TREATMENT OF GUNSHOT FRACTURES. 

The treatment of gunshot fractures of the extremities varies in de- 
tail, depending upon the character of the injury to the bone and to the 



124 GUNSHOT AND OTHER WOUNDS .IN MILITARY PRACTICE. 

soft parts. Three, clinical varieties may be recognized: simple per- 
forating fracture, extensive comminution with moderate injury to the 
soft parts; and extensive comminution with great laceration and de- 
struction of soft parts. 

(a) The treatment of simple perforating fracture is exceedingly 
simple, is in fact nothing but the treatment of the skin wound, viz.: 
aseptic occlusion and immobilization. The result is invariably good, 
provided infection is kept out of the wound. 

(b) By moderate injury to the soft parts is meant more or less en- 
larged wounds of entrance and exit, without extensive laceration. In 
such a case, it is the opinion of most authorities, that conservatism 
will give the best results. 

The skin in the region of the wound is sterilized and the wound also, 
if obviously infected, although it is usually sufficient to cleanse the 
skin — nothing more — and apply an antiseptic dressing and immobilize. 
A variety of splints are available for the fixation. 

" Immobilization is a more difficult problem. In practised hands, 
plaster-of-Paris splints answer most requirements, except in the case 
of the thigh, but the splints take time to apply and also to set firmly and 
as something needing frequent removal, are not altogether suitable 
for field hospital work. Of all the splints I saw in use, I think the 
best were wire splints and the Dutch cane folding splints (Figs. 89, 90) 
for the thigh and leg; wire gauze splints with steel margins or strips 
of ordinary card-board applied \^ith some variety of adhesive bandage 
for the arm and forearm; and plain wooden splints of various lengths 
for any situation." (Makins, Surgical Experiences in South Africa.) 

Senn says referring to the Spanish-American war that it is a source 
of regret that fixation of the fractured limbs by plaster-of-Paris splints 
was not more generally practised. Owing to the want of reliable 
plaster-of-Paris, we had to resort to various kinds of splints and single 
and double-inclined planes. 

In some cases extension will also be required. Transportation is to 
be avoided as much as possible, for the reason that it always aggravates 
the difficulties of keeping the wound sterile. There is no advantage 
which transportation will secure, w^hich will offset the advantage of an 
aseptic wound. 



TREATMENT OF GUNSHOT FRACTURES. 1 25 

(c) The third class of cases, those with extensive comminution and 
great destruction of the soft parts, always raises the question of amputa- 




FiG. 89. — Dutch cane field emergency splint for lower extremity. (Ma kins.) 

tion. The question of viability hinges upon the blood supply, and if 
it is determined definitely that it is cut off, immediate amputation is 
indicated. 



126 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 

On the other hand, if the blood supply is yet intact, however much 
the bone may be shattered, it is advised to sterilize the wound, get the 
fragments in as good position as possible and dress antiseptically and 
immobilize as before. In any case of doubt either as to repair or in- 
fection, this conservatism is proper. 



<^?^ ffjiuSf . 


i 


aKHK'Bwi .' H^^^^^^^^Ih ^^WtIBK 


^ 


^ 1 T S ^ 


^H 


" " ' 


- : ■ - -.^^ _ - _ -•. - 





Fig. 90. — Cane splint for upper extremity. (Makins.) 

Later a line of demarcation or a dangerous sepsis may call for am- 
putation; on the other hand, the suspected tissues may heal without 
interruption. 

If infection occurs, osteo-myelitis may arise and a fatal issue is 
likely. 



TREATMENT OF GUNSHOT FRACTURES. 1 27 

Senn sums up in this manner the modern treatment of recent gun- 
shot fractures: 

1. No probing of the wound. 

2. No primary debridement. 

3. Early efficient first aid dressing. 

4. Immobilization of fracture, preferably by plaster splints. 

' 5. Immobilization combined with extension, if there is a tendency 

to undue shortening. 
"6. First aid dressing must not be removed unless this becomes 
necessary by tbe appearance of local or general symptoms 
that indicate the existence of wound infection. 

Each of the bones of the extremities presents a few special features, 
which may be hurriedly noted. 

The humerus is quite frequently wounded. The most characteristic 
complication is musculo-spiral paralysis, either immediate or remote. 
As a rule, perforation of the upper end gives little trouble to the 
joint. 

The ulna and radius are usually injured separately. The ulna, on 
account of its superficial location, is often the seat of explosive exit 
wounds. This is also true of the lower end of the radius. 

The phalanges suffer much, the tendons are lacerated and acquire 
adhesions, or the fingers may be completely carried away. 

With respect to the treatment, the perforating wounds of the humerus 
are cleansed and occluded. The comminuted wound is wiped clean 
of debris, an ample dressing applied, and the arm immobilized with 
light splints. Paste-board splints are as good as any, applied wet, 
molded into shape and fixed with adhesive strips. 

The femur is quite often wounded and is a fertile source of mortality. 
There is a tendency to great shattering of the shaft, although, owing to 
its deep location, the woilnd of exit is rarely "explosive." Transverse 
fracture is rare. Perforation of the lower extremity is common. 

These fractures are nearly always accompanied by shock, both con- 
stitutional and local. As a result of local shock, shortening is often 
delayed, only to be quite marked when the muscles regain their tone. 

The prognosis is extremely bad in the case of the upper third, but 
better for the middle and lower third. Punctured wounds and com- 



128 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE, 

minuted fracture with small skin wounds are treated by aseptic occlu- 
sion and immobilization. 

Comminuted fracture with large wound of exit requires a more 
formal cleansing, first of the skin and then of the wound, with removal 
of the fragments of bone which will stand no chance of reunion. The 
wound is not sutured and drainage is usually unnecessary. If trans- 
portation is necessary, plaster-of-Paris is the safest dressing. 

For the field hospital, Makin recommends some adaptation of the 




4 .« * ^ «,/ 

Fig. 91. — Hodgen splint for fractured thigh. (Moullin.) 

Hodgen splint as the best, most practical and efficient (Fig. 91). 
Uncontrollable hemorrhage, great injury to the soft parts or grave 
infection call for amputation, but this is very rare, as the result of these 
wounds. 

The tibia and fibida present conditions of special importance. The 
soft parts are often severely injured, the vessels are implicated and, 
in the case of the extremities, the joints are involved. Suppuration 
is common, followed by secondary hemorrhage and purulent arthritis 
(Fig. 92). 

Conservative treatment is the l^est rule — asepsis, careful dressing. 



TREATMENT OF GUNSHOT WOUNDS OF JOINTS 



129 



immobilization. In ordinary cases, any form of splint will do, but 
the plaster-of-Paris is probably the most satisfactory. 

The joot is important in respect to these injuries, for not only are 
several bones involved but also several joints. Infection, unfortu- 
nately, is not uncommon. 

The first dressing must insure immol)ilization in a good position. 

Treatment of Gunshot Wounds of the Joints.— Makin says, 
''We had merely to do our first dressings with care, fix the joint for a 
short time and be careful to com- 
mence passive motion as soon as the 
w^ound was properly healed, to obtain, 
in the great majority of cases, perfect 
results." 

Infection is the chief danger. If 
suppuration occurs, an immediate 
arthrotomy is indicated except in case 
there is much comminution and disor- 
ganization, when amputation will be 
the safer measure. 

The shoulder joint may be involved 
directly or by fissure from the shaft. 
Perforating wounds furnish an ex- 
cellent prognosis. Aseptic occlusion 
and immobilization usually effect a 
cure in three or four weeks. In the 
severer cases, cleanse thoroughly, 

ligate bleeding vessels, restore the parts as nearly as possible, pack 
lightly with gauze, cover amply and infection will usually be avoided. 

The elbow may be injured along with the humerus and ulna; the 
prognosis is worse when the humerus is involved. The olecranon 
may be perforated without injury to the joint. Anchylosis is frequent, 
but even if suppuration occurs, a good joint may be obtained. The 
joint is immobilized in the position of flexion. 

The hip joint seems not to be very frequently wounded, but the prog- 
nosis is bad, both on account of infection and complications such as 
wounds of the bladder, rectum, great nerves, etc. 
9 




Fig. 92. — Perforation of lower third 
of tibia. (Makins.) 



130 GrXSHOT AXD OTHER WOrXDS IX AnLITARY PRACTICE. 

Anchylosis and shortening in an abnormal position must be expected. 
Greatly lacerated wounds call for amputation: the moderately severe, 
for conservative treatment. 

The knee joint is xery frequently wounded, and the damage is always 
serious; any or all of the component structures may be injured. Per- 
foration of the joint without injury to the articular surfaces is a possi- 
bilit}'. Hemorrhage into the joint is a constant feature. This hemar- 
throsis disappears in about a month in the favorable cases. 

Under conservative and expectant treatment, the results are sur- 
prisingly good. On the battle field, the wound is covered with a first 
aid dressing, and some sort of splint applied. At the dressing station 
or field hospital, the dressings may be removed and further cleansing 
applied if necessary, and the limb immobilized in extension. As soon 
as the flesh wound has healed, passive motion is to be begun. If sup- 
puration occurs, arthrotomy must be done without delay. 

The ankle is usually involved along with several bones and joints. 
either directly or by fissuring. The degree of comminution is variable. 
On account of the foot coverings, these wounds are nearly always badly 
infected and phlegmons are frequent. 

For these reasons secondary amputations are frequent, but the treat- 
ment must be conservative. Immobilize the foot at a right angle and 
be on guard for suppuration. 

Treatment of Gunshot Wounds of the Skull and Brain. — 
Perforating wounds of the skull will always be a certain source of 
mortality. The fatalities increase as the range shortens and as the 
base is approached (especially the base in the middle and posterior 
fossa), due to destruction of the automatic centers or to their depression 
following concussion, hemorrhage or intra-cranial edema. The most 
recoveries follow injury to the frontal lobes and the occipital lobes, 
although bhndness may result from the latter class of injuries. 

Primary union of the scalp wound is an element in favorable prog- 
nosis, since by this means infection is often shut out. 

First aid on the battle field will look to the hemorrhage and the 
use of the first aid dressing, which should aim to include both the 
wound of entrance and exit. If the visible hemorrhage is dangerous, 
do not pack the wound, for that will only cause compression. A few 



TREATMENT OF GUNSHOT WOUNDS OF THE SKULL. 13I 

strips of sterile gauze, loosely placed in the wound, will favor both 
hemostasis and antisepsis. 

At the dressing station, or better still, at the field hospital if the 
symptoms are not too urgent, a craniectomy must be done. 

All surgeons experienced in recent wars, agree on the necessity of 
exploring every such wound as soon as possible. 

Shave and cleanse the scalp and then cleanse the wound. Raise 
a flap with the base toward the blood supply and with the entrance 
bullet hole in the center. Enlarge the wound in the skull sufficiently 
to introduce a finger and determine the presence or absence of frag- 
ments within the cavity. Enlarge the wound as necessary, to clear 
the brain -of debris. All splinters must be removed. The brain 
pulp and clots are to be wiped out with sterile gauze and the wound 
closed with only such drainage as the original wound of entry will 
afford (See urgent craniectomy). 

The subsequent treatment requires the patient to be kept as quiet 
as possible, his diet limited and bowels kept open. 

If sepsis occurs, there must be no hesitation in reopening the wound. 

" Such cases of sepsis needed secondary exploration, and the won- 
derful success of this operation was perhaps one of the most striking 
experiences of the surgery in general." (Makins, Surgical Experiences 
in South Africa. 

Treatment of Gunshot Wounds of the Face. — The chief dangers 
in gunshot wounds of the face are hemorrhage and interference with 
respiration. These wounds are also much predisposed to infection. 
The eye, the fifth and seventh nerves are most likely to be involved. 
If hemorrhage cannot be controlled by ordinary means, the facial, 
the temporal, or even the external carotid arteries may need to be li- 
gated. Careful cleansing and packing with iodoform gauze secure ex- 
cellent results. 

Treatment of Wounds of the Neck. — These wounds are always 
dangerous, and yet in no region does the unexpected more frequently 
happen, in the passage of a bullet. The fact of hair-breadth escape of 
important structures is explainable only by the small size of the army 
bullet and the mobility of the structures. The commonest form is the 
transverse or oblique track. Such wounds as are not immcdialoly 



132 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 

fatal are likely to permit recovery. If sepsis occurs, it usually has its 
origin in the air passages or esophagus. 

Injuries to the trachea commonly give rise to broncho-pheumonia, 
hemoptysis or emphysema. 

Many patients with injury of the esophagus will die of sepsis, with 
perhaps a gangrenous condition of the esophagus. Such wounds of 
the large vessels as do not produce immediate death, give rise to many 
instances of arterio-venous aneurism. 

The spinal nerves on the pneumogastric may be injured If the 
recurrent laryngeal is divided, hoarseness, aphonia, laryngeal cough 
and occasional vomiting will be the result. Stevenson reports cases 
with injury to the cervical sympathetic, in wdiich the most prominent 
symptoms were suppression of sweating, myosis, and pseudo-ptosis 
on the injured side. As a rule, no special treatment aside from anti- 
sepsis is required. Tracheotomy may be called for; and if the spine 
is fractured, immobilization will be necessary. 

Treatment of Wounds of the Spine. — These wounds are so ex- 
tremely fatal that nothing more need be said of the treatment than 
that it should be conservative and the patient should be moved as 
little as possible. If the patient survives with pressure symptoms, 
then later on a laminectomy is to be considered. 

Treatment of Wounds of the Thorax. — The non-perforating 
wounds need only an antiseptic dressing. Broken ribs will require 
adhesive strapping. 

The perforating wounds presenting no special indications of hemor- 
rhage from the chest wall, are to be treated by aseptic occlusion. 

The internal mammary or the intercostal arteries may need to be 
controlled. If the hemorrhage is visceral, opium and compression of 
the chest wall by firm bandaging seem to be the last resort in time of 
war. Under no circumstances is the wound to be probed or examined 
with the finger. Transportation is always to be feared. In every 
way, the patient is to be kept as quiet as possible. He must be made 
to realize the seriousness of his injury. Paracentesis should not he 
performed in the case of hemothorax until the bleeding has ceased. Thorac- 
otomy is to be performed if suppuration occurs. (See injuries of 
thora?<). 



I 



SHELL AND SHRAPNELL WOUNDS. 133 

Treatment of Gunshot Wounds of the Abdomen. — Non-perforat- 
ing wounds require only aseptic occlusion. Perforating wounds are 
ahvays to be regarded seriously, yet uncomplicated wounds of the 
solid viscera heal without difficulty. Of the hollow viscera, the as- 
cending and descending colon and cecum give the best prognosis fol- 
lowing perforation. The stomach is not quite so favorable and the 
transverse colon and small intestine give the worst prognosis. Un- 
doubtedly, recovery may follow perforation of even the small intestine 
by the army bullet. 

"The innocuousness of the abdominal wounds inflicted by the 
Japanese bullet, is often w^onderful. * * ♦ s^ of perforating 
wounds of the abdominal cavity, twenty-five cases came under treat- 
ment; no operation was possible or attempted. Within twelve days, 
seven died, a mortality of 28 per cent. Some of these cases had 
traveled forty miles in rough carts, others came on horse back; only 
a few were brought on stretchers; eight arrived with peritonitis. That 
only seven died under such conditions is, indeed, most remarkable." 
(Colonel Valary Havard, Ass't Surg.-Gen'l, U. S. A. in the Journal 
Ass'n Military Surgeons.) 

In warfare practice, nearly all authorities reluctantly admit the in- 
efificiency of operative treatment for this class of gunshot injuries, and 
the better, though unsatisfactory results, of conservative treatment. 

SHELL AND SHRAPNELL WOUNDS. 

These wounds are for the most part lacerated wounds, although 
some- of the smaller fragments of shell (Fig. 93) or the round balls of 
the shrapnell (Fig. 94), may produce perforating wounds, resembling 
those of bullets. 

Naturally, a large proportion of such wounds wall be fatal, laying 
open the great cavities, lacerating the viscera or manglini: the 
limbs. 

They are, in effect, infected wounds and are to be treated on (lie 
general surgical principles applicable to infected lacerated wountls. 

The leaden bullets of shrapnell are often retained and are to l)o 
removed except when sunk in the chest, abdomen, or pelvis. 



134 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 

BOLO WOUNDS. 

According to Foxworthy (Ft. Wayne Medical Journal, June, 1902) 
every insurgent in the Philippines, was armed with a bolo. " This bolo 
was of iron with a wood or bone handle and varied in shape and size 
from a sword to a dagger, and from a corn knife to a meat ax. It was 
generally a cruder weapon than the Cuban machete, but very effective 




Fig. 93. — Fragments of Vickers-Maxim one-pound shell. (Makins.) 

in close encounters. As it could be concealed beneath the loose jacket, 
it was more serviceable than a sword or saber, which was always visible. 
The kries is a weapon similar to the bolo, but with a wavy edge like 
a Christy bread knife. It is often two edged. The wounds produced 
by the bolo and kries were often of great length and usually infected." 
"Another class of wounds was caused by spears and tomahawks, 
used by the Igorrotes and Negrites. The tomahawk having a con- 



FIRST AID ON THE BATTLE FIELD, 



135 



cave edge, was not so apt to glance off the skull as an Indian tomahawk. 
A blow split the skull wide open. 

"The spears were often of bamboo, sharpened to a fine point, and 
their penetrating power was almost equal to that of an iron-tipped 




Fig. 94. — Normal, deformed, and fractured leaden shrapnel bullets. (Makins.) 

spear. The iron-tipped spear had from one to four barbs which made 
an exceedingly ugly penetrating wound and usually had to be cut out. 
These wounds were always infected and tetanus frequently developed." 



FIRST AID ON THE BATTLE FIELD. 

Colonel Nicholas Senn, in his address before the Lisbon International 
Medical Congress, 1906, has accurately defined the principles of first 
aid on the battle field and his conclusions are herewith summarized. 

(i) The fate of the wounded depends largely upon the time and 



136 



GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 



thoroughness with which first aid is rendered. This first aid for many 
reasons cannot be rendered by the surgeon, but must be given by 
comrades of by the wounded man to himself. First aid administered 
in this manner will be eft'ective, owing to the aseptic character of the 
chief wounds of battle, if previous instructions have been given. It is 
absolutely essential that the soldier should receive this elementary 
instruction when he is taught the art of war, and it should not be 
postponed as has been done only too often in the 
past, until war clouds make their appearance. 

(2) The first aid dressing should combine sim- 
plicity with safety against post-injury infection. It 
should be on the person of every combatant and 
must be simple to be efi&cient. It must be compact 
and easy of application. 

"The dressing consists essentially of two pads of 
cotton, wrapped in gauze, and fastened together by 
two stitches and continuous with a gauze roller, 
which is made use of instead of the triangular 
bandage for holding the dressing in place and for 
immobilizing the injured part. The gauze roller 
should take the place of the triangular bandage in 
every first aid dressing as it requires much less space 
and is more serviceable as a means of fixation and 
support. 

''The brown iodine spot in the center of the pad 
on the side to be brought in contact with the 
Fig. 95-— Elevation wouud, corresDonds with the location of the anti- 

01 the upper extrem- ' -^ 

0/ 'h e^m o^rrh2^^"^ septic powder incorporated in the absorbent cotton 
(^®^°-) and serves as an infallible guide in applying the pad 

in the right place." 

(3) The first aid must have in view the treatment of shock and 
hemorrhage, dressing of the wound, and immobilization of the 
injured part. 

The treatment of sJiock in the field is very unsatisfactory, but, for- 
tunately, shock is not a characteristic of small caliber bullet wounds. 
Rest in the recumbent position; hypodermatic injection of one-fourth 




FIRST AID ON THE BATTLE FIELD. 



137 



grain of morphia; spirits internally; these answer the most urgent 
indications. 

The treatment of hemorrhage at the front must be conducted with 
the greatest caution. Elastic constriction, if too generally practised, 
will do vastly more harm than good. It should be applied only in 
exceptional cases and then by a competent member of the hospital 
corps or a medical officer, who must make it his duty to send the 




Fig. 96. — Gun-stack for elevation of the lower extremity. (Senn.) 



case to the first dressing station as quickly as possible, where defini- 
tive hemostasis can take the place of the constrictor. There are less 
harmful means of hemostasis which will be efficient in most cases: 
elevation of the limb (Figs. 95, 96), acute flexion of the joint above the 
wound (Figs. 97, 98), digital compression over the dressing — these 
are measures which must be taught. 

Direct treatment of internal hemorrhage of any of the large cavities 
is entirely out of the question at, or near, the firing line. Tlie cart- 
ridge belt, suspenders, or gunstrap, can be u.sed to the greatest ad- 



138 GUNSHOT AND OTHER 'wOUNDS IN MILITARY PRACTICE. 

vantage in limiting respiratory and abdominal movements and thus 
secure for the vascular bleeding organs a condition of rest, conducive 
to spontaneous arrest of hemorrhage (Fig. 99). 

Immobilization is an essential part of first aid treatment, conducing 
to primary repair, relieving pain and preventing infection by securing 
the first aid dressing. 




Fig. 97. — Forced flexion of forearm in arresting hemorrhage from 
the brachial artery opposite the elbow-joint or any of its branches 
below this point. (Senn.) 

The ideal fixation splint in such cases would be the plaster-of-Paris 
splint, but this method of fixation is entirely out of the question on 
the firing line and must be reserved for the dressing station or Field 
hospital. This first aid fixation must be extemporized. The sound 
leg may serve as a splint for the wounded one which is held in place 
by belt, gunstrap, handkerchief, etc. The rifle, bayonet and saber 
are always available as splints (Figs. 100, loi, 102). 



THE FIRST DRESSING STATION. 



139 



A fractured humerus may be splinted to the side of the body. A 
well-padded bayonet will meet the indications in fracture of the fore- 
arm. The wire netting cut in the shape corresponding to the fixation 
of the different fractures of the limbs should be carried to the front by 
the sanitary corps in sufficient quantities to meet the expected re- 
quirement. Splints made of this material well padded, will answer 
an excellent purpose as first aid fixation, as they can be molded into 
shape and can be used subsequently to strengthen the plaster bandage 
at the dressing station. 

(4) The first dressing station is the most important place for skilled 




Fig. 



-Genuflexion in the treatment of hemorrhage from the popliteal artery and 
its branches. (Senn.) 



^aid. This primary depot of the wounded should be established in a 
sheltered place as near as possible to the firing line, protected as much 
possible against the fire of the enemy. 
(5) Probing of recent gunshot wounds must be prohibited by the 
most stringent rules. Under no circumstances should attempts be 
made to remove bullets, until this can be done under strict aseptic 
precautions in the hospital, and then only in those cases in which such 
operation is clearly indicated and the exact location of the bullet has 
been determined by palpation through the intact skin or by the use of 
the "X-Ray." 

(6) The surgeon's most important duties at the first dressing 
station are: 

(a) Inspection oj first aid dressing. If it is in its proper place, 
label to this effect that it may not be unnecessarily removed at the 
hospital. If defective, it must be renewed or more securely fastened. 



I40 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. 



(b) Application oj plaster splints to the fractured limbs; the wire 
netting splints are cut into strips and incorporated in the plaster-of- 
Paris dressing. 

(c) Emergency operations. The operative treatment of gunshot 
wounds must be limited to the most urgent cases. The definitive arrest 
of hemorrhage — of dangerous external or internal hemorrhage — stands 

pre-eminent in the list of emergency opera- 
tions. Iodized catgut is the proper ligature 
material for field service. 

Intra-cranial and intra-thoracic hemorrhage 
should not be interfered with outside of a 
well-equipped hospital. Dangerous intra-ab- 
dominal heniorrhage calls for prompt opera- 
tive interference. Abdominal section under 
such circumstances in a tent, may contribute 
much in lessening the mortality from hemor- 
rhage by a resort to ligature, suture, or aseptic 
tamponade. 

By pursuing this aggressive course, some 
lives may be saved by prompt interference, 
which would be lost by the let-alone treat- 

"^ ^ Wounds of the larynx and trachea which 

have given rise to respiratory difficulties, either 
Fig. 99.--Temporary treat- from emphysema or hemorrhage, call for an 

ment or penetrating wound ^ •' ° ' 

of chest by antiseptic tarn- immediate trachcotomy. 

ponade and immobilization -' 

(Senn^)^'^^^^^ compression. Rescctiou, as a primary operation for pene- 
trating gunshot wounds of the joints, is obsolete. 

Amputation must be reserved for cases in which a limb has become 
mangled by a cannon ball or fragment of shell, or in which the fracture 
is complicated by division of the principal blood vessels and nerves. 

Laparotomy in the field, for gunshot wounds of the abdomen, with 
a view of finding and suturing perforations of the gastro-intestinal 
canal, has not yielded in practice the anticipated results, and hence 
must be restricted to exceptional cases. 

Clinical experience has shown, that in a fair percentage of cases 




THE surgeon's FIELD CASE. 



141 



penetrating wounds at, and above the level of the umbilicus, inflicted 
in the antero-posterior direction, do not implicate the gastro-intestinal 




Fig. 100. — Saber splint for leg and thigh. (Senn.) 

canal, and in such cases conservative treatment yields better results 
than operative. On the other hand, in wounds involving the small 
intestine area, more especially when the bullet takes an T)blique or 




Fig. loi. — Gun sphnt. (Senn.) 



transverse course, we may confidently expect to find from three to 
fifteen perforations, and it is this class of cases in which immediate 
laparotomy offers the only chance of saving life. 




Fig. 102. — Stick and blanket splint. (Senn.) 



(7) The surgeon's field case should be light, compact, and the 
instruments wrapped in a canvas roll, so that instruments and envelope 
can be quickly sterilized in boiling soda solution. 



CHAPTER XII. 
GUNSHOT WOUNDS IN CIVIL PRACTICE. 

The projectiles of the ordinary fire-arms of civil life differ from 
those used in warfare, in that they are composed of soft lead, are easily 
deformed, are of slight initial velocity, and are usually fired at short 
range. 

The revolver and pistol, flobert and shot-gun produce the wounds 
most frequently seen. 

Of the shot-gun, it may be said that the wounds which it produces 
are very likely to be either greatly destructive or comparatively harm- 
less. At close range the charge acting as a single body, lacerates and 
shreds the tissues; at long range, a number of small perforations 
are made. 

The dangerous wounds, then, have all the characteristics of lacera- 
tions and demand the treatment of lacerated wounds in general. It 
must always be assumed that foreign bodies have been carried into the 
tissues and that these wounds are therefore infected. 

It is the bullet wound of the revolver, however, which it is most 
practical to consider. To a limited extent, its pathology is similar 
to that of the army bullet, and it is unnecessary to state again the 
effect of a bullet upon the various tissues. It is expedient to consider 
at once, with especial reference to treatment, the bullet wounds of 
certain localities. 

WOUNDS OF THE HEAD. 

The region of the brain is usually wounded in atterhpts at suicide, 
and it is the right temple or forehead which is most frequently selected. 
The vertex, postero-lateral and occipital regions are seldom wounded 
and only then as a result of accident or assault. 

As medico-legal questions are often involved in these cases, it is a 

142 



TREATMENT OF BULLET WOUNDS OF THE HEAD. 143 

wise practice to make careful and systematic examinations. Learn 
as much as possible about the character of the fire-arm, the nature of 
the projectile, the position of the patient at the time of injury. Ex- 
amine the ears and nose for blood, inspect the mouth, examine the head 
for a wound of exit or see if the bullet can be located beneath the 
scalp. 

Next examine the w^ound itself, but not until the field and wound 
have been sterilized. Begin the disinfection by shaving the scalp 
about the wound. Wash with soap and water and then with alcohol 
or bichloride. 

Enlarge the wound by a cross incision, if necessary, and wipe out with 
sterile gauze, removing all forms of foreign bodies. 

Finally examine the skull. If you find a mere depression without 
penetration, it is sufficient to pack the opening with sterile gauze and 
bandage. Later the bullet may be located with the ''X-ray" and 
removed, if it becomes troublesome. If the bullet is visible and 
removable, without much difficulty, it is better to take it out at once. 

If the ball has penetrated the entire thickness of the skull and lodged 
within the cavity, the size of the orifice will be some index as to its 
probable depth; if the orifice is large, it argues for close range and 
deep lodgment. If the opening is small, comparatively speaking, it 
is likely that the ball has not penetrated deeply. Note the direction of 
the fissures. If the base is involved, the prognosis is always serious. 
Note the condition of the dura; it may be lacerated and the brain 
tissues may exude. If such is the case, the bullet is obviously in the 
brain, but its exact location must remain a matter of doubt. It is not 
expedient to explore for it; it is not even advisable to attempt to dis- 
infect the cerebral wound. 

It is sufficient to remove all fragments of bone and debris and wipe 
the wound dry with sterile gauze. On these two points, however, 
there may be some difference of opinion. The American Text-Book 
of Surgery insists upon the value of disinfection of the entire cerebral 
track of the bullet and of through and through drainage under certain 
circumstances; also upon the advisability of attempting to locate the 
bullet by the aluminum gravity probe, and to remove it. Still it may 
be said that the general practitioner has done his duty and done it well 



144 GUNSHOT WOUNDS IN CIVIL PRACTICE. 

if he has cleansed the skull and dural wounds and controlled the 
hemorrhage. (For further details of treatments, see urgent craniec- 
tomy.) 

WOUNDS OF THE FACE. 

These may result from shots into the mouth with suicidal intent. 
Small bullets may remain imbedded in the hard palate or posterior 
pharyngeal wall. The instinctive tilting of the head backward 
gives the bullet a characteristic course through the hard palate or the 
root of the nose, and owing to the involvement of the base of the brain, 
such wounds are deadly, except with quite small fire-arms. 

In other cases there are grave comminuted fractures of either jaw. 
Sometimes there are powder burns and disintegrations, suggestive of 
explosions. 

The chief dangers in cases not immediately fatal are from inter- 
ference with respiration and from hemorrhage. These wounds are 
also predisposed to infection, and as a result of sepsis secondary 
hemorrhage is not infrequent. Paralysis of the facial nerve may occur. 
The salivary glands or their ducts may be injured and give rise to a 
troublesome dribbling of saliva. Marked interference with respira- 
tion may call for immediate tracheotomy. 

Arteries may need to be ligated and ligation may be difficult owing to 
their relation to the bones. The oozing, always marked, is to be con- 
trolled by pressure. The natural contour is to be restored as much as 
possible, after a thorough cleansing, and the wound cavities packed 
with iodoform gauze. 

GUNSHOT WOUNDS OF THE THORAX. 

Gunshot wounds of the thorax do not differ from other wounds in 
this region, except in their graver prognosis. (See page 120, wounds of 
thorax, and page 89, military practice.) Such as involve the great 
vessels at the root of the lungs and most of those which involve the 
heart, are not even of interest from a standpoint of treatment because 
so rapidly fatal as to preclude intervention. 

Such wounds as are not obviously fatal, whether they involve the 



BULLET WOUNDS OF THE ABDOMEN. 1 45 

pleura and lungs or the pericardium and heart, present three sources 
of danger: hemorrhage, asphyxia, and infection. These are the three 
conditions which determine the line of treatment, and which have 
already been discussed under the head of wounds of the thorax. 

Aside from these symptoms of urgency, the treatment must be con- 
servative and expectant— quite different from gunshot wounds of the 
abdomen. 

Begin by covering the wound with an aseptic compress and -then 
carefully disinfect the field. Finally cleanse the wound itself and dress 
antiseptically. Avoid probing or other explorations. 

Transportation must also be avoided, for there can be no doubt that 
it is often disastrous. In the country, where ambulances are out of 
the question, the nearest shelter is the best. 

BULLET WOUNDS OF THE ABDOMEN. 

With reference to prognosis and treatment, these wounds fall into 
three clinical groups: those which are obviously penetrating and 
accompanied by grave visceral lesions; those which are doubtful both 
as to penetration and visceral injury; and those which are probably 
benign. 

(A) One concludes that a certain wound is grave, not from observ- 
ing the escape of gas and fecal matter or hemorrhage from the wound, 
for these are too infrequent to be relied upon, but from the general 
condition, which alone is of sufficient significance. The pulse is 
small and rapid; the face is drawn and pale; the belly wall is distended 
and resistant to the least pressure; dullness of the iliac fossa and flanks 
develops and there may be vomiting of stomach contents or of blood. 

The persistence of these symptoms for the first two or three hours is 
sufficient to dispel any illusion of the more sanguine that the case is not 
dangerous. 

There is but one thing to do, operate as soon as possible. 

This is a principle so definitely established that the citation of a 
long list of eminent authorities is unnecessary; a rational doctrine 
that all may accept. 

There are contingencies of time and place, of septic environment 



146 GUNSHOT WOUNDS IN CIVIL PRACTICE. 

which would insure that the operation itself w^ould likely be fatal, but 
those conditions are very exceptional in civil practice with the doctor 
who has the "savoir-faire." An exceptional condition does not alter 
the principle, and he who does not act at once, must incur the re- 
proach of having refused the wounded the best resource of safety. 

There is another consideration. One may not be called to see the 
case until after two or three days have elapsed and may then encounter 
one of two eventualities; one almost certain, the other unlikely. 

In the first, there are the signs of general peritonitis. Under these 
circumstances again, the rule is to operate, though only as a forlorn 
hope. 

On the other hand, it may be that despite the apparent gravity of 
the wounds, the pulse is good, there is no vomiting, the abdomen is not 
tender, there has been a passage of flatus or a movement of the bowels. 
Although we know these appearances are often deceitful, that it may 
be only the lull which precedes the storm, yet w^e are perfectly justified,, 
under these circumstances, in maintaining an "armed expectancy." 
Under such circumstances, control peristalsis with a little morphia, 
impose an absolute quiet and absence of food, and in the meantime 
have the patient under vigilant surveillance. 

(B) The case is one of doubtful penetration and therefore doubtful 
visceral injury. 

You are called immediately. You find nothing more than a 
bullet wound in some part of the anterior abdominal wall. The 
pulse is good, the abdomen is neither rigid nor tender and there is no 
other indication worth noting. 

Now, what are you to do ? Wait several hours watching for some 
indication ? But this is a dangerous formula, subject to various inter- 
pretations, for, as Lejars asks, what shall be regarded as the first 
"indication," — the weaker pulse, the tympanites, the altered facies? 
But these are the signs of beginning peritonitis. 

It is better, as Brown, of St. Louis, and many others, have so defin- 
itely determined, to answer the question resolutely in these terms: 
prepare at once to operate; determine whether the wound is a penetrat- 
ing one or not, and if so, proceed with the laparotomy — provided, 
of course, that the situation is such that it can be done without very 



LAPAROTOMY TOR BULLET WOUNDS. 147 

grave danger from the operation itself. It may develop that the 
operation is not necessary, but it will very much more frequently be- 
come evident that it is indispensable. 

Admit that these urgent laparotomies are difficult, that they strain 
every resource of emergency antisepsis and surgical skill, that the per- 
forations are often multiple, that one never knows just what he must 
meet. Admit that some recover from these wounds without opera- 
tion, but are we authorized by that to expect in another case so for- 
tunate a denouement? Admit that the patient has several chances of 
recovery without operation perhaps, but let us remember we have no 
means of calculating such chances even in the more favorable cases, 
and certainly the chance of an exceptional process cannot give more 
hope than an early, regulated, and aseptic intervention. 

It is prudence which commands operation. As Lejars says, this 
seems the wisest course: 

Prepare for a laparotomy. Begin by cleansing the field of operation 
and then the wound, which is enlarged, cutting from above downward, 
layer by layer. If the peritoneum is found uninjured, repair the in- 
cision carefully, first trim^ming the devitalized tissues away; under 
these circumstances, one may safely prognosticate a recovery. 

If you find the peritoneum perforated, slightly enlarge that wound 
also, that you may get some idea as to the conditions; a flow of blood, 
bile, intestinal contents, or urine may indicate what one may expect. 
But the fact alone of perforation of the peritoneum is an indication to 
open the abdomen in the middle line — to do a median laparotomy. 

The median incision will be above or below the umbilicus, depending 
upon the level of the bullet wound (see laparotomy for traumatism). 

(C) There are finally, as Lejars points out, certain bullet wounds 
which even though penetrating, may be regarded as unlikely to have 
produced serious results. These are such as are produced by pistols 
in w^hich the bullet is quite small and impelled by an insignificant 
charge of powder, so that its force is practically spent in traversing the 
abdominal wall. 

And even though the digestive tube should be wounded, the opening 
is not large enough for the contents to escape and the mucous mem- 
brane acts as a plug and repair quickly takes place. 



148 GUNSHOT WOUNDS IN CIVIL PRACTICE. 

In such a case, there being no doubt at to the facts, it is perhaps 
wiser not to operate but to treat by aseptic occlusion. Nevertheless, 
it is the part of prudence, however sanguine of the outcome, to keep 
the case under close watch for some days. 

GUNSHOT WOUNDS OF THE JOINTS. 

The knee, which is the joint most frequently wounded, may serve as 
a type. Suppose it is wounded by the discharge of a fowling-piece, 
a not uncommxon accident. The character of these wounds is variable. 
It may be that only a few shots at long range have penetrated the 
joint, or it may happen that the whole load has torn its way into the 
joint structure. But whatever the condition, no active intervention is 
called for if the case is seen at once. 

Cover the wound with sterile gauze, provide a temporary splint and 
supervise the transportation. Once provided with shelter, proceed to 
carry out a methodical cleansing and examination. Cleanse the field 
first and then the wound itself. 

If the wound was received at long range and probably only a few 
shots have penetrated the joint cavity, the careful cleansing, antiseptic 
dressing and subsequent immobilization will be all that is required to 
bring about an uninterrupted recovery without loss of function. 

If the wound was received at close range and the joint is freely pene- 
trated by the shot, which have carried in shreds of clothing and other 
foreign particles, the treatment is quite different. 

Suppose the joint is swollen, dark blood oozes out, and the cavity is 
exposed through lacerated wounds; in such a case conservatism will 
not cure. Prepare to operate immediately. Open the joint and with 
hot normal salt solution freely flush out the shot, fragments of bone 
and cartilage, blood clots and other debris. Do not be sparing of time 
and patience. Trim away the lacerated tissues. If satisfied with 
the cleansing, suture the deeper layers over the joint so as to close it 
completely, and drain only the superficial wound; otherwise, drain the 
joint cavity as well. Apply an antiseptic dressing and imm.obilize, 
and expect a good result. 

The situation is again different if the case has been treated first by the 



WOUNDS FROM TOY PISTOLS. 1 49 

uninstructed. The wound is seen some time after injury and found 
covered with dirty cloths, or a handkerchief, the worse for usage, is 
stuffed into the wound. No covering at all is always better than any- 
thing less clean than a sterile dressing. 

The treatment is the same as before — in every way as rigorous and 
systematic — but there are not the same certainties by any means that 
it will head off sepsis. You cleanse, drain, immobilize and watch. 
You watch for beginning infection, which for that matter may develop 
in the simpler cases if the cleansing is not complete. Fever, pain, 
swelling of the joint, all rapidly increasing, are the signs of beginning 
infection and suppuration, and call for immediate action. It is in- 
dicated to open the joint and drain. (See page 340, arthrotomy.) 

Bullet wounds produce similar lesions, although usually they are of 
the milder type. Hemarthrosis indicates injury to bone as well as 
soft parts. Sometimes these wounds occur with scarcely any injury to 
the joint structure, the bullet lodging in the epiphysis. In the milder 
cases, wherever the bullet may be, it is better merely to cleanse and 
immobilize, and at a later date, if necessary, the ball may be removed. 
If, however, the hemarthrosis is voluminous, it is better to open the 
joint at once and clean out the cavity and, by a happy chance, the 
bullet may be found and extracted. (See also gunshot wounds of 
joints in military practice, and compound dislocations.) 

WOUNDS FROM TOY PISTOLS AND BLANK CART- 
RIDGES. 

Two things are noteworthy in connection with these wounds: 
first the surprising power of penetration of cartridges supposed to be 
harmless; and second, the great danger of a tetanus infection. The 
"wad" may be buried out of sight in the tissues, it may entirely per- 
forate the hand, or it may produce a superficial laceration. As a rule, 
the hemorrhage is insignificant, which may in a measure account for 
the development of infection, since bleeding is nature's means of 
disinfection. 

These wounds often present the appearance of punctured wounds, 
which more than others are likely to furnish conditions favorable to 
the growth of the tetanus bacillus. 



150 GUNSHOT WOUNDS IN CIVIL PRACTICE. 

It may be that the disposition of the wad is such that the wound is in 
a manner stopped up, so that oxygen cannot reach the recesses where 
the bacillus finds its lodgment. It is true that tetanus develops in only 
a small percentage of cases, but one can never foretell positively what 
such a wound may do. 

It is the duty of every doctor to warn his clientele of the danger of 
these "Fourth of July" injuries. 

Every case is to be treated as if lock-jaw is not merely a remote 
possibility, but a probability. Free cleansing and douching with 
peroxide of hydrogen is indicated. 

Luckett says (American Journal of Surgery, July, 1906): "These 
wounds should be freely incised, particularly if not seen on the first 
day of the injury, and thoroughly curetted with a small sharp spoon 
until all the small pieces of wad, the unburned grains of powder and 
all the dirt have been removed. If the wad has entered a metacarpal 
space, a counter-incision must be made for through and through 
drainage. Having cleaned the wound as thoroughly as can be done 
mechanically, we now resort to chemicals and irrigate with some mild 
antiseptic. After next drying the wound thoroughly, the entire cavity 
should be swabbed out with one of the following, named in order of 
choice: 

"i. Pure carbolic acid followed by alcohol. 

"2. Twenty per cent tincture of iodine (made by dissolving iodine 
crystals, 20 parts, in ether and alcohol, each 50 parts). 

"3. Plain tincture iodine. 

"The w^ound should now be packed with moist iodoform gauze. A 
wet dressing is then applied, to be changed daily. Permission should 
be obtained for a prophylactic injection of antitetanic serum. Ten 
c.c. are intra-miuscularly injected in the buttocks or thigh, under 
thorough antiseptic precautions." 

Antitetanic powder may be applied to the wound, as advised 
by Calmette. Experiments conducted by Joseph McFarland, of 
Philadelphia, corroborate Calmette's statements as to the prophylactic 
value of this substance. By its use McFarland was able to protect 
from infection animals which he had inoculated with the tetanus 
bacillus. 



CHAPTER XIII. 
FRACTURES. 

Definitions. — A fracture is a solution of the continuity of bone due to 
traumatism. 

A simple fracture has a single line of solution and there is no lesion 
of the soft parts. 

A multiple fracture has more than one line of solution of continuity 
in the same bone or several bones. 

A comminuted fracture has so many lines of solution running into 
each other that the bone is in fragments or splinters. 

A complete fracture involves the whole thickness of the bone. It 
may be transverse, longitudinal, oblique, dentate or comminuted. 

In an incomplete fracture, the line of solution does not involve the 
whole thickness or extent of the bone. It may be a fissure, "a green 
stick," a depression or a separation of an apophysis. 

A subcutaneous fracture has no communication with the surface. 

An open or compound fracture has a communication with the surface, 
has an accompanying solution of continuity of the skin and the sub- 
jacent soft parts. 

A spontaneous fracture is produced by an insignificant traumatism 
and is usually pathological, due to disease of the bone. 

An ununited fracture is one in which bony union has not occurred at 
the usual time. 

Gunshot fractures are those produced by projectiles (see gunshot 
wounds j. 

The symptoms, the diagnosis, the prognosis and treatment vary 
with the region involved, and with respect to these factors fractures 
may be divided as follows: 

Fractures of the skull. 

Fractures of the face. 

Fractures of the spine. 

151 



152 FRACTURES. 

Fractures of the thorax. 
Fractures of the extremities. 

FRACTURES OF THE SKULL. 

Fractures of the skull are important practically only from the point 
of view of their complications, which number three; infection, hemor- 
rhage and injury to the brain. 

In a given case, one or all of these complications are possibilities, 
although for the development of each, certain combinations of cir- 
cumstances are peculiarly favorable. 

With respect to these variations, fractures of the skull are of two 
classes: fracture of the base, and fracture of the vault. Each has its 
special symptomatology and prognosis, though the one may merge into 
the other and the clinical picture be more or less blurred. 

Either may be fissured, fragmented or compound, with or without 
depression. In either the immediate gravity depends upon the nature 
and extent of the injury to the brain, and fractures of the base are the 
more serious, merely because the more important areas of the brain 
are there. 

With regard to the remoter consequences also, fractures of the base 
are less favorable; hemorrhage and its resultant complications are 
more to be feared and infection is a more certain eventuality owing to 
the communications opened up between the cranial cavity on the one 
side and the ear, the nose, or the pharyngeal region on the other. 

The symptoms in either kind of fracture are such as arise from con- 
cussion, compression, or laceration of the brain and are general or focal, 
that is to say, emanating from certain cerebral areas. 

FRACTURES OF THE BASE. 

Fractures of the base of the skull are more frequently indirect, the 
force being transmitted through the spinal column from some part 
of the vault, or the ramus of the jaw; occasionally direct by a thrust 
through the mouth, a blow on the root of the nose, or upon the mastoid 
process. 

Any or all of the fossa: may be involved. Fracture through the mid- 



DIAGNOSIS OF FRACTURE AT THE BASE. 1 53 

die fossa is most frequent and the most serious is fracture through the 
posterior fossa (Fig. loi). 

These fractures are nearly always compound, which adds to the 
gravity of the prognosis The external meatus, the nasal cavities and 
the naso-pharynx are all prolific sources of meningeal infection. 

The diagnosis is usually by inference, often impossible. There 
are certain symptoms always suggestive of fracture at the base, but nol 
to be relied upon exclusively. 

Ecchymosis in the tissues about the orbit, or hemorrhage into the 
sclerotic, appearing first some little time after the injury, and gradually 
progressive — fracture through the anterior fossa suggests itself. Per- 
sistent bleeding from the nose following head injury must be given due 
consideration. Bleeding from the external meatus, copious and per- 
sistent, suggests fracture through the middle fossa. Late ecchymosis 
over the mastoid or into the tissues of the back of the neck suggests 
fracture through the posterior fossa. However, these hemorrhages 
must not be mistaken for local rupture of mucous membrane or other 
soft parts and their absence does not necessarily mean absence of frac- 
ture. 

The bleeding, if intra-cranial, may come from rupture of the middle 
meningeal or the internal carotid or the sinuses. Instead of the bleed- 
ing, or accompanying it, there may be escape of cerebrospinal jiuid. 
Its presence is pathognomonic of fracture of the skull and it must 
be distinguished from ordinary serum g,nd the fluid of the middle ear 
by these characteristics: the flow begins at once and continues for 
several hours; the quantity is considerable, sometimes a tablespoonful 
in fifteen to twenty minutes; the flow is temporarily increased by the 
increase of intra-cranial pressure, sneezing, coughing and vomiting; 
alkaline in reaction; contains only a trace of albumen and is rich in 
sodium chloride. 

Useful in definite diagnosis are the paralyses of the cranial nerves. 
Recall their origin, course and functions. The facial, optic and tri- 
facial nerves are especially likely to be involved. Added to these 
symptoms, but not particularly helpful in the diagnosis of fracture, 
may be those of concussion, compression or laceration. All these con- 
ditions may exist with or without fracture. 



154 FRACTURES. 

The treatment has two ends in view, the prevention of further irri- 
tation of the brain and the prevention of infection. 

Keep the patient absolutely quiet in bed with the head elevated, ap<- 
ply ice bags and keep the bowels open. 

Whenever fracture of the base is even merely suspected, carefully 
wipe out the external meatus and pack with sterile gauze. Do liot 
syringe the meatus or at least only very gently, lest infection be forced 
through the fissure. 

Remove the gauze as often as it becomes soaked with blood, which 
may be at frequent intervals for several days. Spray the nose and 
throat wdth peroxide of hydrogen or a similar mild antiseptic. These 
regions cannot be sterilized but bacterial activity may be minimized. 
Do not pack the nares except for persistent nasal hemorrhage, as the 
packing irritates the mucosa and unduly stimulates secretion, and this 
is undesirable. If packing is deemed necessary, pack with sterile 
gauze saturated with sterile vaseline. In the great majority of cases, 
active intervention is quite out of the question. 

FRACTURES OF THE VAULT. 

Fractures of the vault of the skull may be fissured, comminuted 
or compound, any one of which may be complicated by concussion, 
compression, contusion or intra-cranial hemorrhage. The symptoms 
belong to the brain complications rather than to the fracture itself. 

Simple, fissured fracture without depression is practically impossible 
of diagnosis. The diagnosis is easier if depression is present and yet 
certain injuries to the scalp simulate fracture with depression. A 
blow crushes the soft tissues and around the crushed area marked 
swelling ensues. The sensation to the examining finger is that of a 
depression of the bone. Do not be misled. 

Comminuted fracture of the skull even without depression is gener- 
ally diagnosed -and yet a hematoma may mask the fragmentation. 
Be on your guard in that matter. 

The inner table is always more injured than the outer (Figs. 103, 104). 

The prognosis is good and the treatment simple in fissured fracture 
without depression and without symptoms indicating compression. 



COMPOUND FRACTURE OF THE SKULL. 



155 



iil 



Put the patient to bed, keep the bowels open, limit the diet and 
await developments. Uninterrupted recovery usually follows, yet 
the exceptions to this rule are not infrequent and one must be on his 
guard for intra-cranial hemor- 
rhage. Or later, there may de- ^^.^r^^^^^^^l 
velop symptoms which are ex- ^^^^^^^^^^^^ 
plainable only on the hypothesis ^^^1 
of contusion of the brain. 

If at any time symptoms arise 
indicating the occurrence of 
hemorrhage, say from a ruptured 
middle meningeal, immediate 
intervention is indicated. Some 
surgeons go so far as to recom- 
mend operation for every frac- 
ture of the skull, but that seems, 
at the present time, to radical. 

If the fracture is comminuted 
or even only fissured, with de- 
pression, the chances are so great 

that there is an injury to the brain that even with no symptoms 
present, immediate operation is indicated. (See urgent craniectomy.) 



i 




Fig. 103 



Fracture of outer table from 
mpact of a hammer. (MouUin.) 



COMPOUND FRACTURES OF THE VAULT. 



Much more serious from every point of view are the compomid 
fractures of whatever origin. The constant element of danger is in- 
jection. Add to this concussion, contusion or laceration of the brain, 
and the outlook is grave indeed. The treatment is not so simple but 
its purpose is quite definite, viz.: to prevent infection. 

This is accomplished not by keeping the streptococci out of the 
wound — they are already in; not by destroying them with strong 
antiseptics, as these are too injurious to the brain tissues; but rather 
by removing the conditions favorable to bacterial growth. 

To this end, operation is imperative. As in gunshot fractures, en- 
large the wound, remove extraneous matter, elevate depressed frag- 



156 



FRACTURES. 




are nevertheless of the 
origin fundamentally, 
are 



ments, check the hemorrhage and remove clots, trim away devitalized 
tissues and provide drainage [see craniectomy). Careful attention 
to these details results in the starvation of the germs present with the 
result that repair proceeds. 

Skill in diagnosis, prognosis and treatment in fracture of the skull 
depends upon a clear understanding of the mode of causation and the 
symptoms of contusion, compression, and concussion of the brain. 
Although presenting quite a diverse clinical picture separately con- 
sidered, these three conditions 

same 
They 
each merely a complex of 
symptoms expressing, on the 
one hand, varying degrees of 
either functional depression or 
stimulation of the cortex of the 
brain, or on the other, of the 
deeper centers of the cerebrum 
and medulla. The cortex is the 
seat of consciousness and at the 
same time the most sensitive 
part of the brain; therefore it is 
the first to be affected by condi- 
tions disturbing the circulation 
of the brain. 

The deeper centers, those governing respiration and circulation, 
are not so readily affected. The result is that loss of consciousness 
is the first phenomenon following a general disturbance of traumatic 
origin. This trauma may not be sufficient to reach the cardiac and 
respiratory centers at first or at all; or it may only stimulate them; or 
finally it may paralyze them as well as the cortex. It must likewise 
be constantly remembered that stimulation of these basal centers means 
retardation of pulse and respiration; depression of the same centers 
means acceleration of pulse and respiration, and acceleration is an 
indication of approaching failure. 

It is only by reference to these first principles that one may explain 



..^ 




Fig. 104. — Same; fracture inner table. Note 
greater comminution and depression. 

(MouUin.) 



CONCUSSION. 157 

and reconcile the variations in the derangements of these functions 
of consciousness, circulation, and respiration in different cases. 

CONCUSSION. 

This is in all probability due to a molecular disturbance of the brain 
substance, and is accompanied by neither microscopic nor macroscopic 
change. The disturbance may be (a) moderate, (b) severe, or (c) 
profound. 

(a) The disturbance is moderate. Under these circumstances, 
the trauma depresses the cortex but does not reach the deeper centers 
of the brain and medulla, so there is therefore only a fleeting loss of 
consciousness without any change whatever in the pulse and respiration. 

(b) The disturbance is severe. The force depresses the cortex 
but only serves to stimulate the deeper centers, and, as before, there 
is loss of consciousness but there is this time slowing of pulse and 
breathing. Very soon the normal rate returns and a little later con- 
sciousness is restored. 

(c) The disturbance is profound. The cortex is paralyzed and 
profoundly depressed as are also the deeper centers. The result is 
loss of consciousness and this time rapid and weak pulse and shallow 
breathing which may terminate very shortly irr death. In doubtful 
cases, then, the heart is the chief element in prognosis. The pulse 
immediately grows either worse or better. 

Therefore the symptoms of concussion are distinctly fugacious. 
This is its chief criterion. 

If the symptoms once improve and later recede, one may be sure the 
primary concussion is complicated by compression or contusion. 
Added to these phenomena of concussion, though not particularly 
helpful in diagnosis or prognosis, are certain other occasional symp- 
toms, referable to the reflexes. 

In the severe cases, this will usually be the picture : At the moment 
of injury, unconsciousness occurs, immediate and complete. The 
patient is more than unconscious, he is anesthetized. The face is pale 
and sunken and the whole body cool. The pulse is small, rapid and 
irregular. The temperature is subnormal. The breathing is shallow 
and sometimes sighing. The urine and feces may be retained or pass 



158 FRACTURES. 

involuntarily. Repeated vomiting is quite common, especially as 
consciousness begins to return. Following the return of consciousness, 
a stage of excitement occurs. The symptoms of this stage are those 
of meningeal irritation, and in uncomplicated cases rapidly subside. 

The treatment is quite definite. Disturb the patient as little as 
possible in getting him into bed. Lower the head at first and try to 
maintain the body heat with woolen blankets and hot water bottles. 
Carefully stimulate the heart. To this end, apply a mustard draft 
over the heart and inject ether hypodermically or a 10 per cent solu- 
tion of camphorated oil. Repeat these injections frequently, being 
guarded by the pulse. Von Bergmann recommends inhalations of 
ether for the very weak and failing pulse. 

Do not forget artificial respiration. In those severe cases where the 
respiration is dangerously low, it will sometimes tide the patient over 
the danger line. 

In the subsequent stage of congestion, keep the head elevated and 
apply ice caps if the dressings will permit. Keep the bowels open. 
If the excitement and restlessness are pronounced, morphine hypoder- 
mically is indicated. (Von Bergmann.) 

COMPRESSION. 

Any condition, traumatic, inflammatory or neoplastic, which dimin- 
ishes brain room, may induce symptoms of compression of the brain. 
The symptoms and their course will vary according to the manner in 
which the pressure is produced. 

What is said here applies particularly to the pressure symptoms 
originating in depressed fracture or traumatic hemorrhage, though 
much would apply equally well to the pressure of brain abscess or 
brain tumors or meningeal exudates and similar conditions. 

Pressure symptoms have fundamentally the same origin as concus- 
sion symptoms, that is to say, they are an expression of depression 
or of stimulation of the cortex and the automatic centers. In both there 
may be initial stimulation and terminal paralysis. However, this de- 
pression or stimulation is produced differently in the two conditions, 
concussion and compression. 

In the first case, the disturbance of function is brought about by 



BLEEDING FROM THE MIDDLE MENINGEAL. 1 59 

mechanical injury and in the second by interference with the blood 
supply. Sudden diminution in the circulation modifies the functional 
activity of the brain centers. 

The cortex, the most sensitive, is first affected, followed by loss of 
consciousness. The automatic centers are next affected, at first 
stimulated, though each reacts differently; thus the respiratory center 
is the first to be stimulated and by the presence of carbon dioxide which 
was its primal stimulus. The vaso-motor centers are next invaded 
and finally the vagal and convulsive centers. 

In those cases where the circulation becomes gradually slower, 
the order in which these centers and areas are successively affected is as 
follows: the cortex, the corona radiata, the gray matter of the spinal 
cord, the pons and finally the medulla. Now the symptoms origin- 
ating in these various areas as a result of pressure are of two kinds: 

(a) General or indirect. 

(b) Focal or direct. 

Each may manifest itself in two stages: 

(i) Stage of stimulation. 

(2) Stage of depression or paralysis. 

It is the knowledge of these facts which enables us to harmonize and 
reconcile the diverse statements of various observers regarding the 
character and cause of the symptoms of compression. It is in the hem- 
orrhage arising from the middle meningeal artery that the emergency 
surgeon is chiefly interested. Traumatic compression sufficiently 
serious to require immediate operation in nine cases out of ten origin- 
ates in: 

BLEEDING FROM THE MIDDLE MENINGEAL 
ARTERY. 

This may follow injury to the head with or without fracture. The 
fracture may or may not be diagnosed. 

In a typical case the concussion symptoms which supervened im- 
mediately upon the injury disappear after a half hour. The patient 
regains consciousness and the pulse and respiration approximate the 
normal. 

In the meantime, however, the blood from the torn meningeal is 



l6o FRACTURES. 

slowly oozing into the space between the dura and the skull and the 
''free interval" is interrupted by headache, irritability, perhaps deli- 
rium (stimulation of the cortex). The epidural clot grows larger, the 
intra-cranial circulation is more impeded and complete loss of conscious- 
ness occurs (depression of the cortex). Coincident with this, the pulse 
grows slower and stronger, the respiration deep and stertorous 
(stimulation of automatic centers). A little later coma is profound, 
the respiration begins to fail and the heart's action grows rapid, weak 
and irregular (depression of both cortex and automatic centers), and 
finally all the functions of the entire organ are suppressed and paralyzed 
and death ends the scene. 

Along w^ith these general symptoms there frequently occur at various 
stages certain focal symptoms, monospasms, convulsions; monoplegia 
or hemiplegia. 

Usually at the time the decision to operate is made, this will be the 
condition of the patient: He lies inert, unconscious, the pulse full 
and bounding, the respiration deep and stertorous, the skin hot and 
perspiring, the pupils irregular, usually dilated on the side of compres- 
sion, partial or complete hemiplegia of the opposite side. 

Treatment. — With a definite diagnosis once made, there is no differ- 
ence of opinion as to the treatment. It is imperative to operate and to 
do so without delay. Every additional hour adds to the certainty 
of a fatality. The nature of the injury and the focal symptoms point 
to the site of the clot or the branch of the meningeal most probably in- 
volved. 

By trephining, the clot is exposed and removed and the bleeding 
vessel discovered and ligated. (See craniectomy.) 

The pressure symptoms of hemorrhage from injuries of the sinuses 
are identical with those from meningeal bleeding except that they 
develop much more slowly and are likely not to be so typical. Hemi- 
plegia is not always in the side opposite the clot. 

FRACTURES OF THE VERTEBRA. 

Fractures of the vertebra derive their chief importance from the ac- 
companying injury to the spinal cord and are serious in proportion to 
the amount of injury to the cord, ligaments and tendons. 



FRACTURE OF THE VERTEBRA. 



i6i 



Aside from local pain and deformity, the symptoms are such as 
arise from compression or laceration of the cord and vary somewhat, 
depending on the particular portion of the cord involved. Fractures 
of the cervical vertebra are at once the most common and fatal. Frac- 
tures in the lumbo-dorsal region occur next in frequency. The break 
which usually involves the body of the vertebra, but may include the 
lamina or transverse or spinous processes, is generally due to forced 
flexion. Along with the fracture the ligaments are lacerated, the 
muscles torn, the vertebra dis- 
placed and the blood vessels 
opened. There may be present 
paraplegia and disturbances of 
the functions of bowel and blad- 
der; and in addition to these 
symptoms there are certain 
others which are common to 
fractures of the vertebra wher- 
ever located, such as pain, ten- 
derness to pressure and moticn. 
Occasionally one will find devi- 
ations and angular deformities. 
(Fig. 105.) 

The prognosis in a well-defined 
case is always bad, although 
by no means always hopeless. 

The emergency treatment is 
limited generally to transportation and securing the proper bedding. 
The patient must be handled with the greatest care. Sometimes the 
least added pressure on the cord by the movements of the spine may 
produce immediate death. 

The bed must be uniformly soft and smooth. A water bed is ideal. 
If the symptoms of compression are urgent, it is necessary at once to 
make an effort to reduce the fracture by simultaneous traction and 
pressure. While the assistants pull on the head and feet, the doctor 
attempts by pressure to correct the deformity. There is some danger 
of a fatal asphyxia where the fracture is high, in making these manipu- 
II 




Fig. 105. — Fracture of vertebra. (Maullin.) 



1 62 FRACTURES. 

lations, as the patient is turned on his face and the movements of the 
diaphragm may be interfered with. Laminectomy is not to be con- 
sidered when the indications point to complete crushing of the cord. 
In other cases where the pressure symptoms are obvious, a laminectomy 
should be done without delay. 

FRACTURE OF THE BONES OF THE FACE. 

Aside from gunshot fractures (see page 144), the bones of the face 
suffer occasionally from direct violence. 

The nasal hones may be fractured alone or in connection with the 
ethmoid. Bleeding is profuse and deformity apparent. On account 
of infection from either the outside or inside of the nasal cavity, in- 
flammation and necrosis may be a sequela. 

An attempt should be made at once to elevate the depressed frag- 
ments by pressure within the nasal cavity. The reduction may be both 
difficult and painful. General anesthesia may be necessary. 

Check the hemorrhage by mopping the nasal cavity with a solution 
of adrenalin chloride or pack temporarily with sterile gauze. Sub- 
sequently douche the nasal cavity frequently with glycothymoline or 
Seller's solution to prevent infection. 

FRACTURE OF THE SUPERIOR MAXILLA. 

Fracture of the superior maxilla occurs alone or with fracture of 
the malar or other bones of the face. It may be accompanied by 
splintering of the bone, caving of the antrum, loosening of the teeth 
and disfigurement generally. The alveolar process may be broken 
otf. If this is the case, it may be replaced without great difficulty. 

Oftentimes little can be done to correct the deformity. The lower 
jaw can be used as a splint and very little force is needed to retain 
the fragments in position. 

If the fracture is compound, the fragments should be treated con- 
servatively. It is surprising how perfectly they may sometimes be re- 
paired. The vascularity of both bone and periosteum favors this result. , 

With the jaw at rest, a liquid diet should be maintained and fre- 
quent cleansing with alkaline antiseptic fluids. Be on guard for frac- 
ture of the base of the skull. 



FRACTURE OF THE LOWER JAW. 



163 



FRACTURE OF THE MALAR BONE. 

Fracture of the malar bone seldom follows the suture lines. The 
whole bone may be dislocated in a direction corresponding to the 
force. In this manner, the injury may be transmitted to the superior 
maxillary, its sinus and infra-orbital canal, the nose, the orbit and the 
base of the skulj. 

Uncomplicated fractures of the malar bones require little treatment. 
Compound fractures must be treated on general principles. 

It may be possible to replace a depressed fracture of the zygomatic 
process by pressure through the mouth. 



FRACTURE OF THE INFERIOR MAXILLA. 

Fractures of the inferior maxilla occur most frequently just in front of 
the mental foramen, and are usually compound, opening into the mouth. 

The deformity is determined chiefly 
by muscular action and the degree of 
obliquity. 

The diagnosis is rarely difi&cult. 

Reduction, which is indicated by a 
correct alignment of the teeth, may be 
accomplished by bimanual manipulation 
with the fingers of one hand in the mouth. 
This is usually easily done, the chief diffi- 
culty being to retain the fragments in 
position. The prevention of infection is 
likewise important. (Fig. 106.) 

Oliver, of Indianapolis (Ind. Med. 
Journal, 1906), has described the mode 
of treatment most applicable in the 
emergencies of general practice. He 
recommends, as the result of his experi- 
ence, that in the ordinary case, when 

the patient retains the majority of his teeth, the upper jaw be used 
as a splint. 

This is his procedure: before attempting reduction and wiHiout 




Fig. 106. — Fracture of lower jaw. 
Temporary bandage. (Moullin.) 



l64 FRACTURES. 

anesthesia, if possible, he begins by passing a loop of wire (soft iron 
wire, gauge 26 or 28) around the neck of the most available tooth behind 
the break in the lower jaw; a similar loop is. thrown around the cor- 
responding tooth in the upper jaw. Coming forward of the fracture 
the first solid tooth and its fellow above are both looped in the same 
manner. 

Next a similar loop is adjusted above and below on the opposite 
side of the jaw — on the sound side. Altogether six separate wires 
have been used. Each loop is now twisted down tight with a pair of 
pliers, so that the teeth are firmly encircled and the free ends of the 
wires left projecting from the mouth. 

Reduce the fracture as the next step. This is done by pressure and 
traction with the fingers inside and outside of the mouth. 

Immobilize. — This accomplished by twisting firmly together by 
means of the pliers the corresponding upper and lower wires, which 
brings the lower jaw into intimate contact with the upper. 

Liquid diet sucked through the teeth. 

Antisepsis. — Direct the patient to fill his mouth with the antiseptic 
fluid and to churn it vigorously backwards and forth between the teeth. 
This washing should be done frequently each day and especially after 
each feeding. If necessary, as additional support, a plaster-of-Paris, 
or Barton's bandage, may be applied. 

The wires are left for three weeks, or longer in the severe cases, 
and after their removal a bandage should be kept on for another week. 
The patient should be supplied with a small pair of wire cutters and 
directed how to use them in an emergency, such as serious vomiting 
which might result in asphyxia. 

As Oliver observes, this formula may be varied to suit the individual 
case. The many forms of splints need not be here considered. The 
cases of special difl&culty in reducing and retaining, those which are 
compound and those in jaws practically edentulous, require wiring. 
This is an operation simple in theory but more difficult in practice. 

The main points are to make the incision along the lower border of 
tlie jaw, cutting to the bone and letting the middle of the incision fall 
over the line of fracture. The bone is carefully denuded of perios- 
teum. The sutures are not to come in contact with the buccal sur- 



FRACTURE OF THE CLAVICLE. 1 65 

faces. The bones are drilled; the sutures passed and tied, the peri- 
osteum drawn over the sutures and the soft parts partially repaired. 

FRACTURE OF THE RIBS. 

Fractures of the ribs occur most frequently between the fifth and 
ninth and are usually single and without displacement. If the vio- 
lence is sufficient to break a number of the ribs simultaneously, it may 
cave in the chest wall and by perforation of the lung, produce emphy- 
sema, hemoptysis, pneumothorax. Pain and crepitus point to the 
presence of fracture. Detect crepitus by laying the palm over the site 
of the pain or by the stethoscope 

Slight displacements may be reduced by making pressure over the 
site of fracture during inspiration or perhaps by compressing the chest 
from front to back betw^een the two hands 'Apply adhesive strips 
two inches wide over the injured side, beginning at the scapula and fol- 
lowing the course of the ribs around to the sternum. 

Three or four such strips may be necessary and they must be applied 
at the end of expiration. 

The pain will almost always be relieved by such immobilization of 
the chest wall. Those fractures which involve the viscera are consid- 
ered with injuries of the thorax. 

FRACTURE OF THE CLAVICLE. 

Fractures of the clavicle formerly occurred more frequently than any 
other, but are not now so frequent. One-half of the cases are in 
children. The break very much more often occurs in the middle third, 
occasionally in the outer third but rarely in the inner third. In the 
middle third, the inner fragment overrides the outer, the result of the 
action of the sterno-cleido-mastoid and the muscles that pass from the 
thorax to the humerus, and the weight of the shoulder (Fig. 107). 

The patient leans his head toward the injured side and supports 
the elbow, the position of greatest comfort. The nature of the injury, 
the pain, deformity, crepitus and mobility determine the diagnosis. 

Reduction. — Seat the patient on a low stool, direct the assistant to 
stand behind and to grasp the patient's shoulders, steadying the smind 



i66 



FRACTURES. 



one with one hand and Hfting the injured one upward^ backward and 
outward. At the same time the operator stands in front, helping move 
the shoulder and by pressure and manipulation of the clavicle between 
finger and thumb molds the broken ends into place. 

The reduction is complete when the injured shoulder is as long as 
the sound one, measuring each from the sterno-clavicular joint to the 
tip of the acromion, landmarks which can always be defined. Feel 
along the injured clavicle for any irregularities. Apply the dressing. 

(i) If the patient is to be kept in bed for other reasons than the 





Fig. 107. — Fracture of clavicle. Inner fragment 
lifted upward bysterno-mastoid. (Moullin.) 



Fig. 108. — Velpeau's bandage for 
fractured clavicle. (Stewart.) 



clavicular fracture, it wdll be sufficient to keep him on his back with 
a small pillow between his shoulders and with the hand lifted to the 
chest. 

(2) Any bandage or dressing which draws the shoulder upward, 
outward and backward and holds it in that position will serve. Of 
the dressings, a number are especially recommended. They need to 
be applied for three or four weeks (Fig. 108). 

In ordinary practice, the Sayre's dressing is excellent. The essen- 
tials are two adhesive strips three inches wide and long enough to go 
once and a half about the body, absorbent cotton, roller bandages. 
Begin by fixing the end of one adhesive strip loosely about the injured 
arm just below the armpit. The loose end carried around the body 
will pass over the lower ends of the scapulae. Before completing the 



mayor's sling. 



167 



turn about the body, place layers of cotton wherever the cutaneous 
surfaces are to be in contact. The turn of the adhesive strip about 
the body is completed. This holds the shoulder in the backward and 
outward position (Fig. 109). The hand is drawn across the chest 
toward the sound shoulder and the second adhesive strip is applied. 
Fix one end over the sound shoulder and pass it across the back to the 
elbow (Fig. no). It covers the point of the elbow and follows the 
arm across the chest to the starting point (Fig. in). It is designed 




Fig. 109. — Sayre's dressing. Fig. no. — Say re's dressing com- Fig. 
First stage. (Moullin.) pleted. Posterior view. (Moullin.) 



[I. — Anterior view. 
(Moullin.)- 



to lift the shoulder upward. A few turns of roller bandage around 
the chest lend additional support and complete the dressing. 

Mayor's sling serves an excellent purpose here as well as in certain 
injuries to the arm. It is applied in this manner: 

Take a square of strong, unbleached muslin, or similar material, 
large enough to reach easily about the body, fold it into a triangle. 
The elbow having been flexed to an acute angle and the hand carried 
toward the sound shoulder, the bandage is carried across the tlcxod arm 
and around the chest, its upper level being just below the level of the 
axilla (Fig. 112). The two points are fastened behind with a safety 
pin or tied. 



i68 



FRACTURES. 



,Now turn the third point of the triangle upward between the flexed 
arm and the body and carry it up over the shoulder of the injured 
side (Fig. 113). Mold the bandage vv^ell, so that it fits and supports 
the forearm snugly. The dressing is completed by bands crossing 



HH^BI 


n 


■ 


BBPr ^^^p^^f^^^^^^^^^^^^^mt^^ 


1 


^^^H 


Jf; "^T^^^^^^^ 


7 


J^^l 


K-' .t^4^^^^ 


a 


H 


H ■ ' r^'i' 


''al 


H 


^^H^Ik' ve^S^' 


£^^^F" --' 


3 


m ~ ^^m i 


W^^^f- _^ 


fl 


1 mm 


n 





Fig. 112. — Mayor' s>ling. First stage. (Lejars.) 

over the shoulders and connecting the anterior and posterior parts of 
the bandage after the manner of suspenders (Fig. 114). 

FRACTURES OF THE EXTREMITIES. 

Fractures of the extremities are emergencies, sometimes of the first- 
class; their reduction sometimes becomes equivalent to a major opera- 
tion. But it cannot be said that these cases are always treated well. 
As Senn says, " Bad results following fractures have been the tombstones 
that have marked the termination of an otherwise successful profes- 
sional career of many an ill-fated, unlucky, disappointed practitioner." 



PROGNOSIS IN FRACTURES. 



169 



Malpractice suits more frequently follow this class of cases, perhaps, 
than any other, which is an indication that somewhere there is a fault. 
Doubtless it is the fear of a damage suit that often makes a basis for 
it and in this way: The doctor, in order that he may have testimony 
as to his skill, treats the case in the stereotyped, and routine way; 




Fig. 113. — Mayor's sling. Second stage. 
The bandage is molded snugly to the arm. 
(Lejars.) 



Fig. I] 



-Mayor's sling completed. 
(Lejars.) 



he gets a bad result. Had he used his better judgment, given his 
common sense rein and risked the reproach of being an innovator, the 
result would have been different. 

Every case must be studied and treated on its own merits, with 
due regard, of course, to certain general principles. To begin with, 
the prognosis should always be guarded in some degree. As King says, 



lyo FRACTURES. 

(St. Paul Medical Journal, August, 1906.): ''Optimism as to the final 
outcome on the part of the physician is a mistake. Take the patient 
into your confidence, let him anticipate the certainty of some permanent 
defect so that in the end an imperfect result will not reflect so much 
upon your skill and will tend to minimize malpractice suits. And 
how very rarely indeed can the result be perfect. With the very best 
treatment there will nearly always remain as the best outcome some 
slight weakness, or limitation, of motion, or ache, or pain — at least a 
callus as a 'lasting memorial.'" 

The diagnosis of these fractures is usually easy in the large sense, 
as King says, but after all difficult as a whole, for no eye can see the 
injury wrought to the softer tissues. In many cases the position will 
indicate at once that there is a fracture, but one must endeavor to learn 
much more — the possible associated injuries to joints, muscles, blood 
vessels and nerves. To be able to do this necessitates a fairly accurate 
knowledge of anatomy to begin with, aided by systematic examinations, 
and on this foundation skill grows with experience. 

The diagjiosis of fracture in the bones of the extremities is based 
on several factors; (a) history of the case, (b) deformity, (c) abnormal 
mobility, (d) pain and loss of function, (e) crepitus, (f) " X " ray 
examination. 

(a) It is essential to know how the accident occurred. Frequently 
in the absence of definite symptoms, the diagnosis must rest upon that. 
For example, in a case of a hip-joint injury in an elderly person pre- 
senting loss of function and some pain but no other symptoms, a diag- 
nosis of impacted fracture should be made if it is learned the patient 
fell striking the hip. 

(b) Deformity includes changes in the relations or dimensions 
of the bones and the appearance of the limb. The two limbs must 
always be compared. It must be determined that there has been no 
previous injury to cause the deformity. When both ends of a bone 
are accessible to touch, it may be readily measured and compared with 
its opposite. In the case of the humerus, it is necessary to measure 
from the acromion; in the case of the femur, from the ilium. The 
position which the fragments assume may be due to the direction of 
the force or the action of the muscles. 



PRINCIPLES OF TREATMENT OF FRACTURES. 171 

(c) Abnormal mobility implies movement in unnatural situations or 
in unnatural degree or direction. 

(d) Crepitus is the almost constant accompaniment of abnormal 
mobility and is the grating produced by the friction of the two fragments. 
It is pathognomonic but must not be sought for too vigorously. It is 
absent in impacted fracture and to break up an impacted fracture, 
testing for crepitus, may be a calamity. Crepitus may sometimes be 
heard with the phonendoscope and not with the ear. 

(e) Pain and loss of function go together since the pain is usually 
the cause of the loss of function. Both are present in nearly all frac- 
tures but often occur in as great degree with contusions. 

The amount of pain varies with the location but is nearly always 
aggravated by movements or pressure. Taken in connection with the 
history of the case, it is a valuable diagnostic aid. The presence of 
pain may call for anesthesia before diagnosis can be completed. 

(f) The '• X " ray cannot be ordinarily available in general practice 
although of the greatest assistance in cases of doubt. Without its use 
many fractures in the region of joints will be diagnosed as something 
else. Bloodgood particularly emphasizes its value (Progressive 
Medicine, Dec, 1906), believing that the doctor who neglects the aid 
of the Rontgen picture when he is able to obtain it will have much to 
regret. There is no danger that its employment will blunt the diag- 
nostic sense. 

The treatment implies a reposition and an immobilization that the 
bones may unite in their normal relations. It has that objective but 
has also another which is not necessarily a concomitant of the first. 
The bones must unite without deformity but there also must be res- 
toration of the limb's junctions. Union in good position, then, is only 
one of the means to a larger end. It is better to say that the treat- 
ment includes reduction, immobilization and mobilization. 

In making reduction, violence must be avoided. Gentle but per- 
sistent effort is always better than rude haste in overcoming the re- 
sistance of muscles and ligaments, which is usually the chief obstacle 
to reposition. The line of traction must be adapted to the muscular 
action. Traction must usually be accompanied by countertraction 
and local manipulation of the broken ends. 



172 FRACTURES. 

In making traction it should be made directly, if possible, on the 
bone involved, without the intervention of a joint. For example, in 
reducing the humerus the traction should be applied above the elbow 
joint. Often an anesthesia is necessary to relax the muscles, and if 
anesthesia was necessary to complete the diagnosis, everything should 
have been prepared previously for the treatment so that only a single 
anesthesia is necessary for diagnosis, reduction and dressing. 

In the cases of suspected fracture in the vicinity of a joint, it is not 
always best to hurry the reduction; often it is better to wait a day 
or so and try to reduce the swelling, for the swelling aggravates the 
difficulties which are always great in the differential diagnosis about 
the joint. 

So far as the shaft of the long bones are concerned, however, the 
formula should be immediate reduction and fixation. That the reduction 
has been complete is attested by the appearances of the limb, by the 
absence of any irregularities to the touch, and by the coincidence of its 
measurements with those of the sound limb. 

Immobilization is a phase of treatment raising many questions 
in dispute. In what manner shall it be applied and for how long? 
Or as Championniere insists, may it not in many cases be dispensed 
with entirely? 

As to the manner in which it is to be attained, let it be said briefly 
that the simplest effective dressing is the best. Its elaborateness will 
depend upon the tendency for the displacement to recur and this 
tendency must be measured by the degree of obliquity of the fracture 
and the action of the muscles. Sometimes the tendency to recurrence 
is an indication of imperfect coaptation. In one case, then, only a 
light retaining splint is necessary and in another it indeed must be 
firm and strong. 

At the present time there can be no question but that plaster-of-Paris 
is the dressing of choice. At any rate it will render the best service 
to the general practitioner who must rely on his own resources in fash- 
ioning splints. Ready-made splints are an abomination. There are 
other plastic materials that are often useful, and in lieu of all these 
materials the splint may be cut into forms to suit the case from boards, 
etc., and applied well padded. 



FIRST AID IN FRACTURE OF THE EXTREMITIES. 1 73 

Walsham formulates the principles which must regulate the use of 
splints in any case. 

1. The splints must be well padded. 

2. Pressure must not be made over the points of bones. 

3. Strapping or bandages must not be put on too tightly. 

4. Circular constriction of the limb must be avoided. 

5. The splints, if possible, should reach beyond the joint above and 

below the fracture. 

6. The patient should be seen within twenty-four hours after the 

splint is applied for the bandage may become too tight. 

7. The splints should not be needlessly disturbed — that is to say, 

if the patient is comfortable and the limb in good condition. 

8. Spasm of the muscles is to be overcome by steady extension. 

9. The part below the fracture should be bandaged, or at least 

raised, to prevent swelling and edema. 

The first immobilization will continue till there is no tendency to 
spontaneous recurrence of the displacement, which will vary in differ- 
ent cases. After this time a dressing must be used which is easily 
changed, and daily massage must be instituted. 

Complete and continuous fixation through a long period is distinctly 
bad practice and most especially whenever a joint is involved. Rossi 
has shown (Wiener Medical Presse, Jan., 1902) that the amount of 
new cartilage formation is proportional to the amount of movement per- 
mitted and is found in the greatest amount in fractures treated by mas- 
sage, and is explained by the greater formation of new blood vessels 
and the consequent more active circulation and absorption of effusion. 

First aid to those disabled with fractured limbs is in civil practice 
more frequently given by others than the doctor. It is desirable, how- 
ever, whenever possible, that he should direct the transportation and 
the preliminary treatment. 

The utmost care must be practised in lifting and handling the broken 
limb, lest the injuries be augmented and a simple fracture converted 
into a compound. 

If fracture is merely suspected, it must be assumed to be present. 
The limb must never be lifted by the foot or hand but must be lifted 
as a whole, resting upon the palms of the hand. Two attendants are 



174 FRACTURES. 

always better than one in handling a broken leg. If the deformity 
is quite obvious even to the unpractised, an effort should be made to- 
ward reduction before applying temporary splints, this with a view to 
preventing further injury to the soft parts. 

The limb is seized by an attendant at each end and gentle and steady 
traction made in the direction of its axis. If this does not succeed, the 
attendants must not persist in the effort. It must be left for the surgeon. 

If the fracture is compound, with severe hemorrhage, the clothing 
must be removed. Otherwise this is not necessary. In removing the 
trousers or a coat, for example, the sound limb is uncovered first and 
then, very gently, the injured one. It is better to cat the clothing or 
rip along a seam. 

A splint is next improvised from whatever may be first at hand, a 
thin board, laths, an umbrella or the branch of a tree. The splint is 
padded, or the limb wrapped with whatever presents itself, a blanket 
or anything to prevent undue pressure, and then is fastened on the limb 
by a cord, or belt, or suspenders, etc., and finally the injured leg is 
bound to the sound leg, the injured arm to the side of the chest or 
carried in a sling. 

The limb thus temporarily immobilized, the patient is ready to be 
moved. 

To lift the patient with the greatest safety in the case of a broken leg, 
for example, one attendant standing on the sound side, places his arms 
under the body of the patient, who in the meantime locks his arms 
about this attendant's neck. A second attendant standing on the 
same side places one hand under the body, one under the sound limb 
while a third attendant facing the others supports the broken limb. 
At his word of command, all lift. This carefulness must not be relaxed. 

If a litter is available, or one can be improvised, it is placed parallel 
with the patient, its feet at his head, so that without any inconvenience 
the patient may be laid upon it. 

FRACTURES OF THE HUMERUS. 

Certain points of anatomy apply to nearly all fractures of the 
arm and are useful in diagnosis, reduction, and treatment. Recall the 
relations of the humeral head to the acromial and coracoid processes; 



FRACTURE OF THE SHAFT OF THE HUMERUS. 1 75 

the great tuberosity; the internal and external condyles; the attach- 
ments of several muscles, particularly the deltoid, biceps and triceps; 
the relations of the musculo-spiral nerve. Remember that in the 
normal relations a line dropped from the tip of the acromion to the 
external condyle will touch the greater tuberosity. The symptoms 
and treatment vary somewhat with the part of the humerus involved. 

Fracture oj the Shajt oj the Humerus. — Above the attachment of the 
deltoid there is not likely to be much deformity; below, the deformity 
will depend upon the degree of obliquity. Usually the displacement is 
not great. 

Reduction. — Seat the patient; the assistant standing on a chair 
lifts the shoulder with a towel passed under the axilla. Now flex 
the forearm at a right angle, holding it with one hand and the arm 
just above the elbow with the other. Make traction on the arm in 
the direction of the axis, gently rotating to disengage the fragments. 
It is a good indication, if there is much grating, that there are none 
of the soft parts engaged. 

Reduction is complete when the acromion, tuberosity and exter- 
nal condyle are in the same line and the arm, the same length as the 
other. (Fig. 115.) If slight rotation is particularly painful think of 
an inclusion of the musculo-spiral. If such a diagnosis is made it will 
be necessary to operate. A general anesthesia may be necessary to 
facilitate reduction. It will not alter the principle of procedure. 
The great difficulty is to maintain the reduction exact until the dress- 
ing has been applied. 

With the idea of insuring the coaptation while the fixation is being 
applied, Lejars very highly recommends the appliance of Hennequin. 
It is equally applicable in some of the other fractures of the humerus 
and is employed in this manner: 

The patient is seated; bandage the injured member from the wrist 
to about three inches above the elbow; protect the axilla with ab- 
sorbent cotton; flex the forearm at a right angle and maintain in that 
joosition in a sling. Pass a band under the axilla and fasten it to 
something (a hook in the wall), so that the shoulder is slightly lifted. 
That is the counter-extension. 

Another band crosses the forearm just below the bend of the elbow and 



176 



FRACTURES. 




Fig. 115. — Testing the humerus for shortening. Measuring from the acromion to 
the external condyle. 



HENNEQUINS DRESSING. 



177 



to it is attached a weight, say of 2 K. G.; that is the extension. Give 
the apparatus a little time and it will effect a reduction as the muscles 
tire. Employ this interval to prepare the fixation dressing (Fig. 116). 

Cut out six strips of crinoline, each about one yard long, and wide~ 
enough to cover the arm at its 
thickest part. Lay these strips one 
upon the other and fasten them 
together and from the sheet thus 
formed, cut a deep scallop out of 
either end — at the lower end 45 to 
50 cm. and at the upper end 15 to 
20 cm. deep. Of the yokes thus 
formed, one will fit into the axilla 
and the other into the bend of the 
elbow, while the intermediate portion 
forms an internal splint for the arm. 

Soak the cloth in liquid plaster 
and apply it in the manner indi- 
cated, molding it carefully to the 
arm. The two upper bands overlap 
the shoulder and the two lower ones 
are wound spirally around the arm 
to the wrist. In this way the 
shoulder and wrist are immobilized. 
In the meantime the extension and 
counter-extension are not disturbed 
until the plaster splint is fuUy^ 
hardened. The dressing may be f^lf^l^^llTlislllTZT^^^ 
further secured by a few turns about applied. (Lejars.) 
the chest. 

Other dressings recommended are the plaster roller from the wrist to 
shoulder; an internal splint with a shoulder cap and sling; or molded 
splints. 

Union requires from six to eight weeks; failure to unite is usually due 
to the interposition of the soft parts. The importance of the musculo- 
spiral nerve in this connection must never be forgotten. 




Fig. 116. — Fracture of shaft of humerus. 



178 



FRACTURES. 



Fracture of the Upper End oj the Humerus. — These injuries often offer 
the very greatest difficulties in diagnosis. Such cases for the most part 




Fig. 117. — Examining the shoulder. Rotating head of humerus. 

present themselves with swollen, painful and contused shoulders, 
deformed, perhaps and functionless. You ask yourself: is it only a 
severely bruised joint ; is it a dislocation or a fracture of the surgical 



DIAGNOSIS OF FRACTURE AT SHOULDER. 



179 



neck or perhaps both; or is it an impacted fracture of the anatomical 
neck; are the soft parts implicated? 

Do not waste time in vague palpations but proceed at once to a 
systematic examination, under chloroform, if necessary. Begin by 
locating the apex of the acromion; if there is no depression beneath it; 
if the thumb cannot be pushed into a concavity but comes in contact as 





JH^ ' 




^^ 




% ■ 




-^ 




-i 



Fig. 118. — Examining the shoulder. Comparing the relations of the coracoid processes.' 



it should with the humeral head, you may conclude there is no dis- 
location. With the thumb still in front, close the fingers on the poste- 
rior aspect of the head of the humerus, and with it thus held firmly, 
attempt rotation of the arm. The humeral head rotates with difficulty 
in dislocation; it does not rotate at all if there is fracture, and besides, 
there is crepitation (Figs. 117, 118). 

A source of error: If the lower fragment overrides much, its rotation 



i8o 



FRACTURES. 



might be felt and mistaken for the humeral head. Abduct the arm; 
easily done in fracture, with increase of deformity. 

Examine the axillary space and all the other aspects of the shoulder 
comparing the two sides, and compare the other landmarks of the 
arm. Do not begin any treatment until the diagnosis is assured. How 
unfortunate it is to attempt reduction of a supposed dislocation by the 
ordinary method w^hen it is complicated by fracture; 
or to treat as a contusion, a fracture wath displace- 
ment ! 

To consider briefly the more common findings of 
such examinations: 

I. Fracture of the surgical neck without overriding 
(Fig. 119) needs only the simplest treatment: Brace 
the arm on the inside with a "V" shaped axillary pad, 



and with the forearm flex at a right angle; support 



the whole extremity in a sling of the Mayor type. 
Additional protection may be afforded by a shoulder 
cap. Begin massage early. (Fig. 120). 

2. Oblique Fracture of the Surgical Neck with much 
Overriding. — These are difficult to reduce; difficult 
to maintain; likely to be mistaken for dislocation. 

Reduction. — In making traction, draw downward 
and outward at first and then in the axis of the limb. 
Do not stop until the arm is the correct length by 
measurement; until the subcoracoid projection has 
disappeared; the acromion, greater tuberosity and 
the external condyle are in the same straight line. 
Extension must be maintained while the dressing is applied or the dis- 
placement will certainly recur. The Hennequin apparatus described 
will be useful here and the plaster splints as well. Sometimes wiring 
is necessary. 

3. Fracture of the Surgical Neck with Dislocation. — This is a very 
serious injury; difficult of diagnosis; of bad prognosis. Carrying 
out the systematic examination described, you find the head dis- 
placed but the arm is not fixed in abduction as in the ordinary dislo- 
cation; it drops to the side. Again, the head does not rotate with the 



Fig. 119. — Frac- 
ture of surgical 
neck of humerus. 
(Moullin.) 



FRACTURE AT SHOULDER WITH DISLOCATION. 



l8l 



arm; there may be crepitation; from these and other confirmatory 
points the diagnosis is made. 

Reduction. — Anesthesia is necessary. Make a slow, gentle, but 
persistent traction on the arm; this combined with manipulation of the 
head of the humerus in the axillary space may succeed in restoring the 
head to the glenoid fossa, for more than likely the head is still attached 
to the shaft by periosteum and muscular fibers. As the assistant 
makes the traction apply your thumbs to the head in axilla and 

with the fingers braced by the , 

shoulder, try to force the head into 
place. 

Once the dislocated head is re- . 
duced, reduce and treat the fracture 
by the ordinary means. Massage 
must be begun especially early. If 
these efforts fail, choice lies between 
operation and expectant treatment. 

Royster, of Raleigh, N. C. (Jour- 
nal A. M. A., Aug. lo, 1907), re- 
views his own experience and the 
literature dealing with this condi- 
tion and concludes very logically 
that operative treatment in the 
great majority of cases, is alone 
effective. 

The preferable incision begins at 
the acromion process, extends 
vertically downward as far as 
necessary and aims to reach the part passing between the pectoralis 
major and the deltoid. The head, thus exposed, is to be reduced by 
manipulation, although occasionally a special hook or bone forceps 
may be necessary. Wiring will seldom be required except in the cases 
operated late. The dressing should be applied so as to maintain the 
arm in abduction. Royster believes in immediate operation, regard- 
ing such cases as emergencies, even as strangulated hernia or ap- 
pendicitis. "Even in cases of doubt, it is preferable to expose the 




Fig. 120. — Fracture of surgical neck. 
Axillary pad; shoulder cap- forearm 
supported in sling. (Scudder.) 



1 82 FRACTURES. 

parts to view rather than to wait in the hope that nature and time 
will clear it up." 

Fracture of the greater tuberosity may occur as the result of either 
direct or indirect violence such as a fall upon the hand with arm 
extended. The displacement of the tuberosity may be upward, out- 
ward and backward. Early disability and swelling are prominent 
symptoms; crepitus may be absent. Taylor, of New York, asserts 
(Annals of Surgery, Jan., 1908) that in uncomplicated cases with 
moderate displacement recovery may be practically perfect without 
the use of splints, massage or special movements. 

Fractures of the Lo-x)er End of the Humerus. — Injuries about the elbow 
are always to be regarded seriously. They occur much more fre- 
quently in children and are usually due to falls upon the flexed elbow. 
Scudder insists that even in the apparently trivial cases the examina- 
tion should be made under anesthesia, for only by that means, as a 
rule, can the injury be exactly diagnosed. 

The diagnosis itself is chiefly a matter of applied anatomy. The 
landmarks and the normal relations must be clearly in mind. Ob- 
serve on the sound side the relations of the internal and external con- 
dyles, the olecranon, the head of the radius. It is uncertain at first 
whether it is a contusion, or dislocation, or fracture. Even when sure 
that the case is a fracture, yet it is to be determined whether it is supra- 
condylar, or condylar, or some combination of the two. 

Scudder formulates a routine mode of procedure in making the 
diagnosis. 

Observe the character of the swelling — whether general or 
localized. 

Observe the carrying angle. 

Palpate the external and internal condyles. 

Palpate the olecranon process and head of the ulna. 

Rotate the head of the radius. 

Note the relation of the three bony points in extension, and flexion 
(Fig. 121). 

Determine the possible movements of the elbow joint. Make 
measurements. 

Certain forms of injury are found most frequently: (i) Supra- 



SUPRA-CONDYLAR FRACTURES. 



183 



condylar fracture, (2) fracture of one of the condyles, (3) multiple 
fracture involving the joint. 

(i) Siipra-condylar Fracture. — The joint is not usually involved. 




Fig. 121. — Examining the elbow; locating the three cardinal points — the internal 
condyle, the tip of the olecranon and the external condyle. 



the plane of fracture extending commonly from above downward and 
forward. The displacement of the upper fragment, thereft)rc, is down- 
ward and forward and if union takes place in this position the tlexion 
of the elbow is much abbreviated (Fig. 122). 



184 FRACTURES. 

Reduction. — Often the ordinary means, that is by traction and 
countertraction with the forearm flexed, will not succeed. Try slow 
and progressive traction upon the extended forearm, aided by manipula- 
tion of the fragments at the site of fracture (Fig. 123). 

When reduction is complete, continue the traction but gently 
flex the elbow to an acute angle; if no displacement occurs, proceed 
to apply the fixation dressing. The molded, posterior plaster splint, 
or trough, is recommended. 

Six pieces of crinoline long enough to reach from the deltoid in- 
sertion to near the wrist, and wade enough to cover the arm, are 
quilted together and two oblique notches cut corresponding to the bend 




Fig. 122. — Supra-condylar fracture of humerus. Note obliquity. (Moullin.) 

of the elbow. This piece of padding is now impregnated with liquid 
plaster and applied to the back of the arm and forearm, and well 
molded. The two notches permit a ready adjustment at the bend of 
the elbow. The support of the arm is not relaxed until the plaster has 
hardened. The gutter thus formed may be strengthened by a loosely 
applied roller which passes from the wrist across to the arm near the 
axilla, around it and back to the wrist again, and so on. 

(2) Fracture of the Condyles. — If the internal condyle is broken, 
swelling is marked over the inner side of the elbow. The condyle can 
be grasped between the fingers and crepitus elicited. The inner 
of the three bony points is displaced upward, which diminishes the 
carrying angle. The ulna is displaced upward in extension (Fig. 124J. 

If the external condyle is broken the swelling is most noticeable 



TREATMENT OE ERACTURE ABOVE THE CONDYLES. 



i8s 



externally. Although the external condyle is dislocated, its relations 
to the head of the radius are not change'd. The fragments in either 
case are likely to be easily reduced by pressure, but the displacement 
immediately recurs when the pressure is removed. 

Reduction. — Grasp the condyle between the finger and thumb of 
one hand and make pressure in the bend of the elbow with the other, 




Fig. 123. — Supra-condyloid fracture of the humerus. Method or reduction before 
applying retentive spHnt. Countertraction on upper arm. Traction on condyles of 
humerus with right hand; backward pressure with thumb of left hand. Also illus- 
trative of method of beginning acute flexion. (Scudder.) 



and while the assistant slowly brings the forearm into the position of 
acute flexion, manipulate the condyle into place. 

Treatment. — Scudder strongly recommends fixation in this posi- 
tion of acute flexion, maintaining it by passing an adhesive strip three 
inches wide about the wrist and upper arm, supporting the whole with 
a sling. He emphasizes the necessity of watching the circulation in 
the forearm and regulating the degree of flexion by the amount of 
swelling. 

(3) The intercondylar and multiple fractures involving the joint, 
as they do, require a very guarded prognosis (Fig. 125). By referring 



i86 



FRACTURES. 



to the landmarks, the displacements are to be figured out and the 
fragments are to be manipulated until all the movements of the joint 
are restored. 

The forearm is then to be acutely flexed and fixed either by the 
adhesive strips, or plaster splints as before described. If the dis- 
placements cannot be held by this means the fracture must be treated 



fll 







Fig. 124. — Frac- 
ture of internal 
condyle. (Moullin.) 



ti% 



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[Z HV^ 



-^ 



I ''\r^' 



^ 



Fig. 125. — Intercondylar fracture 
of humerus. (Moullin.) 



by extension for a few days and then put up in acute flexion. Massage 
and passive motion must be very early begun in these cases and per- 
sisted in for a long time. 

Fractures of the Forearm. — ^Fracture of the sJiajt of the ulna and 
radius occurs more commonly in the middle third, both bones being 
broken or only one. If both are broken, the radius is likely to be broken 
at a higher level than the ulna. There is usually not much deformity 
if one bone is fractured; considerable if both are. 



TRACTURE OF THE FORE-ARM. 187 

The diagnosis is to be made from the pain, deformity, mobility and 
crepitation; supination is particularly painful if the radius is broken; 
lateral compression of the bones, even at some distance from the seat 
of fracture, may elicit much pain. 

Reduction. — ^Flex the forearm at a right angle; direct the assistant to 
make countertraction from the arm; grasp the hand, place the arm 
in complete supination and make traction in the axis of the forearm, 
molding the fragments into place; the fingers following the interosseous 
space down the front of the arm help to force the fragments apart. 
The preservation of the interosseous space is the essential thing. The 
extension and supination must be maintained until the dressing is 




^^^#^^ 



Fig. 126. — Anterior and posterior splint for forearm. (Heath.) 

applied. Whatever its form, the fixation must have one negative 
quality — it must not compress the forearm laterally or else the bones 
may be pressed toward each other and fusion occur. 

Anterior and posterior splints may be used, both wider than the 
forearm. The anterior must extend from the bend of the elbow to 
the base of the fingers; the posterior must extend from the elbow to 
the wrist. They may be shaped out of boards and wxll padded. The 
palm must be well padded. The splints are first secured with adhesive 
strips and then with a roller bandage. The elbow is to be immobilized 
by suspension of forearm and hand in a sling (Fig. 126). Care 
must be taken not to compress the brachial artery, or the bony points. 

Instead of the anterior and posterior splints a plaster cast may be 
used, extending from the axilla to the palm of the hand immobilizing 



I5S riL\CTURES. 

the wrist and elbow: care must be taken not to compress the forearm 
(Figs. 127, 128). 

Lejars recommends the plaster splint formed in this manner: 
twelve to fifteen sheets of crinoKne cut in the form of an irregular quad- 
rilateral, long enough to reach from the bend of the elbow to the 
palmar crease, wide enough above to encircle the arm; below, wide 
enough to more than encircle the wrist, are loosely quilted together. 
In the middle of the lower end, one inch from its border, cut an oval 




Fig. 127. — Method of supporting arm while appl\-ing plaster bandage. 

opening large enough to pass the thumb. This dressing, soaked with 
plaster and molded to the forearm, furnishes a firm fixation. 

CoIIes' Fracture. — This break at the lower end of the radius is quite 
common and is more often due to a fall upon the outstretched palm. 
The lower fragment is pushed toward the dorsal surface and overrides, 
producing the characteristic hump — the silver fork deformit}-. But 
it is by no means seldom that fracture occurs without deformity 
(Fig. 129). 

Diagnosis. — Determine the position of the styloid process of the 
radius and ulna. If there is a fracture the styloid of the radius is 
pushed up to a level with that of the ulna. The transverse lines on 



REDUCTION or COLLES' FRACTURE. 189 

the flexor surface of the wrist are deepened and the axis of the hmb 
bent toward the radial side. The pain is pronounced, mobility and 
crepitus are absent. 

Reduction is often difficult, but it is the chief thing and must be 
complete, otherwise the result will be a disappointment. Anesthesia 
is usually necessary. Clasp the patient's hand in your own, palm to 
palm, and with the other hand grasp the wrist at the site of fracture. 




Fig. 128. — Fracture of forearm. Plaster-of-Paris splint 
applied. Elbow at right angle. (Scudder.) 

While the assistant makes countertraction you make forcible traction on 
the hand, at the same time inclining it to the ulnar side and making 
pressure upon the fragments. This combined traction, pressure and 
ulnar flexion may require force but it will quickly reduce the fracture 
(Fig. 130). 

There is very little tendency to recurrence of the deformity if it is 
properly reduced, and the fixation is a secondary matter. If there 
was no deformity, or a very slight one easily reduced, it may be treated 



I go 



FRACTURES. 



altogether by massage. Otherwise a week's fixation in one of the 

dressings just described is advisable, to be followed by active massage. 

Fracture of the Olecranon. — This break is usually due to direct 

violence, sometimes to muscular action. The amount of separation 




Fig. 129. — Colles' fracture. Silver fork deformity. (MouUin.) 

of the fragments depends upon the amount of the tear in the fibrous 
attachments of the triceps, and is, of course, most marked in flexion 
and is increased by swelling of the joint. A complete fracture opens 

into the joint. 




■ Fig. 130. — Reduction of Colles' fracture. Note grasp upon forearm and the lower 
fragment of the radius, traction and countertraction being made ; breaking up the 
impaction. (Scudder.) 



Much difference of opinion exists as to the treatment. It is obvious 
that no one method is equally applicable to all cases. There can be no 
doubt that the method of choice, where it is possible, is suturing. 

If this is not advisable, or not permitted, the next best procedure 



SUTURE OF FRACTURED OLECRANON. 



191 



is the treatment by massage begun immediately — and this whether 
there is much or little separation. No immobilization, only massage. 
If asepsis can be assured, or if the fracture is compound, suture is 
indicated. The operation is not difficult. The bone is exposed by a 
transverse incision, or if there is a wound it may be enlarged. Cleanse 
the wound of all exudates and trim away the ragged tissues; next expose 
the fracture, separate the fragments and expose and cleanse the joint. 




Fig. 131. — Suture of the olecranon. The suture in the form of a transverse loop 
perforates the lower and two upper fragments. (Schwartz.) 



There are several methods of suture. If the fracture is transverse, 
the periosteum on each side is laid back and two holes drilled in each 
fragment for the passage of two silver wires. When a wire is passed 
its ends are twisted and the coaptation perfected (Fig. 131). The drill 
holes should not involve the cartilage. The wires are cut short and 
hammered down smooth, and the periosteum and fibrous sheath 
sutured, and the skin wound repaired without suture. The arm is 
immobilized in flexion for eight or ten days and then massage is 
begun (Fig. 132). 



192 



TRACTURES. 



If the fragments are split, they may be each perforated from without 
inward and a suture passed and tied on the outer side. By this means 
the fragments are all drawn into coaptation. If the upper fragment 
is small the upper transverse perforation may involve only the tendon. 

J. B. Murphy has devised and recommends a method of subcutan- 
eous suture (Jour. Am. Med. Assn., Jan. 27, 1906). Begin by 




Fig. 



32. — Suture of the olecranon. Repairing the periosteum by a continuous 
catgut suture. (Schwartz.) 



making a small incision over the external border of the olecranon below 
the line of fracture. Through this small opening (ij inches) drill the 
olecranon transversely, and over the point of emergence of the drill on 
the inner border of the olecranon incise the skin again. An aluminium 
bronze wire is passed through the drill-hole from without inward and 
the inner end is pushed up under the skin along the internal border of 



FRACTURE OF THE CARPUS. 



193 



the olecranon to the level of the 
apex of the bone. At this level 
another incision is made, the 
end of the wire reco veered and 
pushed through the tendon of 
the triceps from within out- 
ward. A fourth small incision 
is made over the end of the 
wire to the outside and the end 
of the wire again directed under 
the skin to the starting point 
and there tied tightly, in that 
manner approximating the fragments. 




Fig. 133. — Showing "sway-backed" appearance 
after fracture of the first phalanx of middle finger. 
(Marsee.) 



Fracture will 
and on examination the styloid 
process of the radius is found 
too close to the base of the first 
metacarpal, and the " tabatiere 
anatomique" — the depression 
at the base of the thumb be- 
tween the long and short ex- 
tensors of the thumb — is occu- 
pied by a hard body. Often 
the thenar eminence is ecchy- 
13 



Close the skin wounds. 
Fractures oj Carpus and 
Hand. — Fractures of the bones 
of the carpus are not infrequent 
and may occur with fractures 
at the lower end of the radius. 
The scaphoid is probably the 
most frequently involved, either 
alone or with one of the other 
bones. The injury results 
most frequently from a fall 
upon the hand when it is ex- 
tended and abducted, 
be suspected from the pain and loss of function, 




Fig, 134. — Splint with attachment for correc 
tion of lateral deformity. (Marsee.) 




Fig. 



135. — Mode of adjusting splint for simple 
fracture of the finger. (Marsee.) 



194 



FRACTURES. 




Fig. 136. — Splint wrapped with gauze ad-*. 
justed for fracture of first phalanx, index finger. 
(Marsee.) 



mosed. The exact character of the lesion can only be determined by 

the " X " ray. Reduction may 
be accomplished by putting 
the hand on the ulnar flexion 
and making pressure on 4he 
fragments through the palm. 
Excision may be necessary. 

Fracture of the metacarpals 
is to be reduced by traction on 
the corresponding fingers, com- 
bined with pressure on the 
fragments. Immobilization on 
a simple splint for eight or ten 

days, followed by massage, will give good results. 

Fracture of the pigers is sometimes compound, requiring a careful 

antisepsis. There is usually a 

tendency to displacement, so 

that after reduction splinting 

is necessary. A well-padded 

palmar splint is often all that 

is necessary, retaining it by 

bandages or adhesive strips. 
In many cases, however, the 

matter is not so simple and it 

cannot be denied that the 

splints ordinarily used are often very unsatisfactory, for they are not 

seldom so fashioned as to be 
inadequate to maintain exten- 
sion, to immobilize perfectly, 
or to correct deformity. 

The first or proximal phalanx 
most frequently suffers and the 
fragments are likely to bulge 
toward the palm, giving the 
finger a "sway-backed" ap 
pearance (Fig. 133;. AsMaisee 




Fig. 137. — Finger splint applied. Dorsal 
aspect. (Marsee.) 




Fig. 



138. — Splint applied. 
(Marsee.) 



Palmar aspect. 



FRACTURE OF THE FINGERS. 



195 




Fig. 139. — Lateral angular deformity of 
middle finger. Unsightly stump of index. 
(Mar see.) 



has pointed out, this deformity will not yield to the ordinary splint 
nor indeed to any splint which is straight or but slightly curved. 

The appliance recommended for 
this condition and which may be 
useful in any fracture of the digits, 
consists of a strip of tin, zinc, cop- 
per, or galvanized iron, fourteen 
inches long and two and one-half 
inches wide. This is to be folded 
iipon itself lengthwise and ham- 
mered flat so as to make a three- 
ply strip three-fourths of an inch 
in width. Of whatever material 
made, it should be just flexible 
enough to be bent readily by the 
unaided fingers. Upon one end of 
the strip, a piece of thin leather or 
canvas four or five inches long and 
three inches wide is to be riveted 

(Fig. T34) in order to give the strip stability when bandaged to the 

forearm. The strip is then 
shaped to suit the curved out- 
line, in which position the 
fingers should be immobilized 
(Fig. 135, 136). The splint is 
to be adjusted snugly to the 
forearm, so that its end pro- 
jects slightly beyond the tip of 
the finger, and fastened by 
strips of adhesive plaster, by a 
roller bandage, or by a light 
plaster-of-Paris casing. The 
finger, carefully wrapped in 
several thicknesses of gauze, 
is then adjusted with painstaking care to the splint in such 
a manner that the deformity, if any, is thoroughly overcome, and 




Fig. 140. — Crushed hand. Lateral angular 
deformity of little finger. (Marsee.) 



196 



IRACTURES. 



longitudinal and circular strips of adhesive plaster are applied 
(Figs. 157, 138). 

In this manner, almost complete control of the finger is assured. 

When, however, the lateral 
angular deformity is pro- 
nounced (Figs. 139, 140), some 
modification of the apparatus 
may be necessary. 

Two or three strips of zinc 
or copper are cut out two and 
one-half inches long and half 
an inch in width. These are' 
bent by one end around the 
splint, fitting it snugly but yet 
capable of being slipped back- 
The free end is left wide and is 
This lateral support may 




Fig. 14: 



-Splint applied to prevent lateral 

angularity. (Marsee.) f 



ward and forward along the splin 

bent up to give, the finger lateral support 

be slipped along to the desired 

point and eft'ectually corrects 

the deformity (Fig. 141). 

Should two or more fingers 
be broken, several strips may 
be used side by side, but fast- 
ened to the same flansie of 
leather or canvas. For two 
fingers, a spKntof double width 
may be fashioned. 

Should the thumb be broken, 
the splint may be heated and 
bent laterally in proper shape, 
or an arm may be riveted to 
the ordinary strip. 

If the fracture or dislocation 
is compound, especially if attended with much displacement and 
difficulty in maintaining reduction, the fragment should be exposed 
and wired, for which one needs onlv a small drill or aw], a fine steel. 




Fig. 142. — Suturing bones of finger. 
Drilling. (Marsee.) 



STAVE OF THE THUMB. 



197 



crochet hook and chromicized gut (Figs. 142, 143). Such is the 
method taught by Marsee. 

The after-treatment is of importance. The splint will be required 
probably for two weeks or longer, but in order to prevent stiffness, 
passive motion should be begun at the end of the first week and re- 
peated every other day at first. The fragments must be held in place 
during the first seances. Un- 
der this treatment, the stiffness 
and soreness wall disappear 
together. 

If it is the base of the meta- 
carpal of the thumb which is 
broken, the reduction will be 
difficult to maintain, and it will 
probably be necessary to splint 
for two or three weeks. This 
is Bennett's fracture or " Stave 
of the thumb." Russ, of San 
Francisco, who has given the 
subject special consideration, 
states (J. A. M. Assn., June 
16, 1906) that with an increase 

of Bennett's fracture in their dispensary book, there has been a 
marked decrease in their diagnosis of sprains of tlie thumb and sub- 
luxations of the metacarpo-trapezial joint. He believes it to be the 
most common and most important of the metacarpal fractures. He 
uses three well-padded pencil splints, many cases requring a marked 
abduction of the thumb. 



pn 


^Hj 


V7 


An^ 


n9I 


K 


3^1 


^^ 


^ 


'W^^^k 


H 


■ 



Fig. 143. — Suturing bones of finger. Drawing 
suture through with crochet hook. (Marsee.) 



FRACTURES OF THE LOWER EXTREMITY. 

The first aid in these cases is of special importance, as has already 
been indicated. Even more than elsewhere the principle applies that 
there must be absolutely as little motion as possible in order that tlie 
patient may be spared pain and augmented shock; that the deformity 
may not be aggravated and the periosteum and other soft parts lac- 



198 FRACTURES. 

erated; and that a simple fracture may not be converted into a com- 
pound one with all the additional dangers of infection. The method 
of lifting a patient so injured has already been described. 

Fracture oj the Femur. — The treatment and prognosis of fractures of 
the thigh vary with their location, and, with reference to these points, 
they are divided into three classes: (i) those involving the upper end, 
(2) those involving the shaft, (3) those involving the lower end. 

(i) Fractures oj the upper end oj the jemur have been the subject of 
much discussion, and various forms of treatment have been recom- 
mended for imagined clinical and anatomical varieties. At the pres- 
ent time, nearly all surgeons are of the opinion that these lesions may 
be grouped under two heads, impacted and non-impacted. Even 
this division is not important for diagnosis but only for prognosis, 
since impaction, provided it is not broken up, offers the conditions 
most favorable for bony union. 

Although the differential diagnosis is usually difficult, sometimes 
impossible, yet the presence of a fracture of some kind is usually 
determined after a little study. A severe contusion may indeed be 
mistaken for fracture, but this is not a serious error. On the other 
hand, it is a very serious error to mistake and treat a fracture about 
the hip as a contusion. In the case of unresolvable doubt, treat the 
injury as a fracture. The diagnosis is made from several factors: 

(a) Pain is a symptom upon which one cannot greatly rely. It is 
more constant in impacted than non-impacted fracture because of 
the accompanying bruises of the soft parts. The pain is aggravated 
by pressure over the hip. Tenderness and especially a fullness in 
Scarpa's triangle is frequently observed. 

(b) Loss oj junction may also be due to contusion; moreover, the 
patient may be able to walk with an impacted fracture, so that this 
symptom is no certain criterion. However, the patient is usually 
unable even to draw his heel upward. 

(c) Eversion oj the joot is nearly always present in some degree, 
but is more frequently indicative of non-impacted than impacted 
fracture, and is due to the weight of the limb. 

(d) Shortening is more frequently the accompaniment of impacted 
fracture. It is definitely determined by comparing with the sound 



FRACTURE OF THE NECK OF THE FEMUR. 



199 



side, measuring from the anterior superior spine (be sure the pelvis 
is not tilted) to the internal condyle and internal malleolus; also by 
determining the relation of the trochanter to Nelaton's line (Fig. 144). 

(e) Crepitation is proof incontestable but rarely available. One 
should make no effort to elicit this symptom, fearing to break up im- 
paction, which is an accident much to be deplored, according to the 
usually accepted view. 

Senn (Practical Surgery) says upon 
this point that it is better to be satisfied 
with the probable evidence of fracture. 
If the surgeon in his anxiety to obtain a 
perfect diagnosis moves the limb freely 
in all directions, he overcomes impaction, 
rupturing the cervical ligaments, demon- 
strating beyond all doubt the existence 
of the fracture and at the same time 
eff'ectually destroying all hope of reunion. 
As Senn suggests, a useless limb is cer- 
tainly a high price to pay for a perfect 
diagnosis. 

The treatment resolves itself into two 
lines of procedure, depending upon 
whether or not the fracture is impacted. 
In either case the treatment should be 
modified by the age and constitution of 
the patient. Confinement on the back 
may be fatal in the aged, and it is imper- 
ative in such cases to give the patient 
more freedom. This imperfect immob- 
ilization may eventually result in an im- 
perfect union, but one must be consoled by the reflection that a fatal 
attack of hypostatic pneumonia may have been prevented. 

In the case of undisturbed impaction, the treatment is of the sim- 
plest form. The patient is placed on a smooth mattress, the limb 
supported by sand bags or perhaps light extension applied, and sys- 
tematic massage early instituted. In case there is much shortening 




Fig. 



—Measurement of lower 
extremity. Patient lying on the 
back looked at from above. Posi- 
tion of tape, hands, and limbs to be 
noted. (Scudder.) 



200 FRACTURES. 

with non-impaction and the patient's condition will permit, then the 
case must be treated on the same principles as fracture of the shaft. 
Senn advises prolonged immobilization in a plaster cast, which ex- 
tends from the foot to the umbilicus, and is fenestrated for the purpose 
of applying lateral pressure, which he regards as essential to good 
union. 

J. B. Walker, of New York, is not in accord w^ith the dictum that 
impacted fractures of the neck of the femur should not be disturbed, 
and Whitman agrees with him (Annals of Surgery, January, 1908). 
Unless the condition of the patient forbids, he proceeds gently to 
break up the impaction under anesthesia. The limb is reduced by 
extension and gradual abduction to an angle of forty-five degrees, 
in the meantime supporting the upper end of the femur and rotating 
the leg inward. 

In this position, the limb is well covered with cotton batting, all the 
bony points especially well protected and a flannel bandage smoothly 
applied. A plaster spica is now applied extending from the lower 
ribs to, and including, the foot. The plaster fits the pelvis snugly 
and is molded close to the trochanter and posterior aspect of the joint. 
It is also molded to the patella and condyles and to the foot to prevent 
rotation. This dressing permits the patient to rise up in bed without 
much discomfort. Walker concludes from his experience that 
fracture of the neck of the femur occurs under fifty years more fre- 
quently than formerly believed; any injury of the hip followed by dis- 
ability should suggest fracture and calls for expert examination, aided 
by the "X" ray wherever possible; that reduction of deformity and 
immobilization by plaster bandage in all suitable cases should be 
practised; that early gymnastic exercise is advisable; and that the 
weight should not be borne for three or four months. 

Fracture oj the Shaft oj the Femur. — In this fracture the lower frag- 
ment is nearly always displaced forward and upward. If the fracture 
has been produced by direct force, it may be transverse, but this is 
"he exception. The diagnosis is simple: shortening, eversion, loss of 
unction. 

Manipulation is unnecessary and decidedly to be avoided, not only 
that the patient may be spared the pain but also that the trauma may 



TILLAUX'S DRESSING FOR FRACTURE OF LEG. 20l 

not be aggravated, the periosteum torn, the muscles bruised, the 
vessels injured. 

Reduction. — This must not be begun till all the dressings are quite 
ready. Lay the patient on the floor or on a hard mattress without 
pillows. One assistant grasps the thigh with both hands near the 
pelvis; the other assistant, the foot and lower third of the leg. As 
they make traction and countertraction the surgeon manipulates the 
fragments. The traction must be prolonged as these strong muscles 
relax only gradually. 

When the fracture is quite oblique and the pointed extremities 
are caught in the soft parts, a little patience will be required to free 
the fragments. To effect this, slight rotation and oscillation must 
be added to extension and abduction. 

How will one know that reduction is complete? 

(i) These points must exactly correspond when the two limbs are 
placed side by side: the upper border of the two patellar, the lower 
border of the two internal malleoli, the two soles. 

(2) The limbs must be the same length by measurement from the 
anterior superior iliac spine to the inner malleolus. 

(3) The line dropped from the iliac spine to the malleolus must 
touch the inner border of the patellar. 

Dressing. — Many forms of splints are described; many of them 
complex; all effective in some degree. Whatever the form employed, 
the limb must be frequently measured and the patient's general con- 
dition kept under close watch. Scudder highly recommends a 
modified Buck's extension (Treatment of Fractures, page 300, etseq.). 
Many are more successful with the plaster cast. 

Lejars recommends, as the simplest in emergency practice, the 
dressing of Tillaux. From a roll of adhesive plaster are cut eight or 
nine strips one and one-half inches wide, and long enough to extend 
from the level of fracture down the side of the limb, over the sole of the 
foot after the manner of a stirrup, and up the opposite side of the leg 
to the level of the fracture. 

Begin by applying one of the strips in the direction indicated. Next 
slip a strip transversely under the thigh, another under the calf and a 
third under the ankle and make one circular turn of each. Next 



202 



FRACTURES. 



apply a second longitudinal strip slightly overlapping the first; fol- 
low with another turn of each circular strip, and so on. In this 
manner the strips are given a firm attachment. 

Every point of contact of the adhesive must be perfectly smooth. 
Every longitudinal strip must extend the same distance as its fellows 
below the sole in order that the extension weight shall make uniform 
traction on all the components of the stirrup. 

A cord is fastened to the stirrup, passed through a pulley at the 
foot of the bed and a weight of five to ten pounds attached. If a 
pulley is not obtainable, a hole can be cut in the foot of the bed if it 
is wooden; or the cord may work over a broom handle attached to an 





Fig. 14.S. — Transverse frac- 
ture of patella. (MjuIJin.) 



Fig. 146. — Comminuted frac- 
ture of patella. (MouUin.) 



iron bedstead. The weight must be increased in the case of the 
muscular or in the case of a very oblique fracture. 

Supracondylar fractures derive their importance from the fre- 
quency with which the fragments involve the knee joint or the 
structures in the popliteal space, and from the difficulty of main- 
taining coaptation. Both these characteristics depend upon the 
obliquity of the fracture which usually extends from behind down- 
ward and forward. The complications must be treated on general 
principles. 

The fixation may be any of the means just described for fractures 
of the shaft. In this case as in any very oblique fracture, flexion of 
knee and hip seem specially indicated. 

Hennequin's apparatus, which Lejars describes, secures an effi- 
cient extension, combined with flexion of the hip and knee and permits 
the patient to sit up. Downey, of Gainesville, Ga., has thought out a 
device which involves the same principles as the Hennequin apparatus 



FRACTURE OF THE PATELLA. 



203 



^/ ^' 



but is simpler in application. As Downey remarks (Jour. Am. 
Med. Assn., Aug. 25, 1906) the dressing aims to secure at once 
the position of the Esmarch, Smith, Hodgen or Cabot apparatus; 
the extension of the Buck apparatus; the fixation of plaster-of -Paris. 
This is accomplished by means of a double angular plaster-of -Paris 
splint. 

The mode of application (briefly) is this: Secure countertraction by 
a padded sheet passed between the legs and brought well up against 
the perineum; traction, by grasping the leg above the ankle with 
one hand, under the knee with the 
other. A plaster cast is applied from 
the toes to just above the knee, which 
is well flexed. Now secure coaptation. 

Next apply the second section of the 
cast, beginning at the upper border of 
the first and carrying the roller in the 
ordinary manner up to the ensiform, 
all the w^hile maintaining the traction 
with hip well flexed. Strengthen the 
outer side of the cast at the hip joint 
by up-and-down folds of the roller, or 
by metal splints. Split the splint if 
constriction is feared. 

Fracture oj the Patella. — Fractures 
of the patella are comparable with 
those of the olecranon. They may be 
transverse (Fig. 145), are usually 
fractures resulting from indirect force; 
or they may be vertical (Fig. 146), or 
oblique, or multiple. 

There are two obstacles to osseous 
reunion: the action of the quadriceps extensor and the inlcrventicM-i 
of the patellar fascias preventing exact coaptation. In spite ot those 
unfavorable circumstances, there is generally some form i^f tihrous 
reunion unless the fragments are very widely separated (Fig. 147). 

The treatment of the present time is by one of two methods, mas- 




V' 



Fig. 147. — Fracture of the patella. 
Showing separation of fragments and 
distension of the synovial sac. (Moullin.) 



204 



FRACTURES. 



If the fracture is transverse, with very little separation, 
and the conditions are not favorable for an aseptic operation, massage 
may be expected to give a good functional result. If the separa- 
tion is considerable, massage will still give a better result than any 
splints. 

In any case suturing is the ideal foim, although the ideal cannot 




Fig. 148. — Suture of patella. Method of drilling and passing sutures. (Labey.) 



always be attained. Again, every compound fracture should be imme- 
diately sutured. J. H. Ford, whose experience with these fractures 
has been large, describes his method of procedure in ordinary fracture 
(Ind. Medical Jour., July, 1907), 

In the non-operative cases he begins by elevating the limb for several 
days to relax the quadriceps. If there is effusion he bandages lightly 



SUTURE OF THE PATELLA. 



205 



with a flannel roller, or if the hemarthrosis is marked, a firm con- 
striction is practised, or ice-bags applied. 

/\s soon as the actute symptoms have subsided, which is after three 
to five days, massage is instituted and daily applied. Begin with 
gentle constriction of the joint with the hands by an upward move- 
ment, and ending with more vigorous pressure of the sides of the patella 
and the joint. In the intervals the limb should be maintained on a 




Fig. 149. 



-Suture of patella. Completing repair by suture of periosteum 
and fibrous coverings. (Labey.) 



posterior splint. After from four to six weeks of the treatment, 
he immobilizes the joint in a plaster cast, preferably for two weeks 
more, and subsequently he recommends a morning and evening 
massage and flannel bandaging until the functions are practically 
restored. 

The operative treatment is by no means simple, yet by no means 
beyond the skill of anyone who knows how to secure asepsis and to 
apply a bone suture. Begin with semilunar incision, concave upward, 
well below the line of fracture and reaching to either border of the 
patella. Raise the cutaneous flap and expose the patella. The 



2o6 



FRACTURES. 



articulation is carefully wiped out and freed of all fragments and 
clots. 

Fixing the upper fragment between the finger and thumb, two 
slight incisions are made in the periosteum at the points where the drill 
is expected to enter. Two tunnels are now drilled from above, emerg- 
ing on the face of the fracture well above the line of the cartilage. The 
sutures are drawn through these openings and the process is repeated 
in the lower fragment, but great care must be used in securing a corre- 
spondence with the first two drill holes or the coaptation will be im- 
perfect (Fig. 148). By traction on the sutures the fragments are 
brought together and great care is necessary to avoid including shreds 
of fascia. The sutures are tied, twisted firmly and pressed down 
upon the bone. The periosteum and fibrous coverings are next 
sutured with catgut (Fig. 149J. 




Fig. 150. — Fracture of patella. Circular suture. (Labey.) 



Ford prefers not to wire, but, after approximation, sutures the lateral 
fascia with No. 3 forty day chromicized catgut and the aponeurosis in 
front with No. i. A No. i forty day suture, 18 inches long, is then 
threaded on a strong, half-curved needle which is entered into the 
aponeurosis just above and on a linf' with the outer edge of the patella 



FRACTURE OF THE LEG. 207 

and follows the upper border of the patella to the inner side where it 
emerges; is re-entered and carried down the inner side; again around 
the lower fragment, passing through the ligamentum patella and 
emerging at its outer border. This retention suture is now tied tightly 
at this last point of emergence (Fig. 150). The skin wound is next 
repaired without drainage. The limb is subsequently immobilized 
for two weeks when massage is to be begun. 

Ford lays down these rules respecting the treatment of simple 
tran verse fracture: 

(i) Operative treatment should never be undertaken except under 
the best conditions for maintaining asepsis. 

(2) Even under aseptic conditions not every case should be 
operated on, but only those in which the separation is at least one- 
half inch and the "reserve extension apparatus" is compromised by 
lateral tears. 

(3) Operative treatment fulfills all the indications in a degree 
which the non-operative treatment can only partially achieve. 

(4) Early massage favors complete restoration of function and 
should be used in all cases. 

(5) In operative treatment the open arthrotomy should be used. 

(6) Absorbable suture material applied only to the soft parts is 
sufficient in nearly every case. 

FRACTURES OF THE LEG. 

Fractures of the leg present many variations, but the prognosis 
and the difficulties of treatment depend chiefly upon whether the 
fracture is transverse or oblique. If transverse there is usually slight 
displacement, easily reduced and easily maintained; if oblique there 
may be much obliquity, which is difficult to reduce and hold, and 
often results in much loss of function. 

Transverse fractures more commonly are due to direct force and 
the lesion corresponds to the application of force. Oblique fractures 
are more commonly due to indirect force and the two bones give way at 
their point of least resistance, which in the case of the tibia is at the 
junction of the middle and lower third; in the case of the tibula in tlie 



2o8 



FRACTURES. 



upper third. In general, displacement is always favored if both bones 
are fractured. 

The diagnosis of these injuries usually offers but little difficulty 
The deformity, loss of function, pain and crepitus, and preternatural 
mobility leave but little doubt except when the injury is at the upper 
end, and where the joint may be involved, or when the fibula alone is 
fractured. A useful test for fracture of the 
iibula is compression of the two bones some 
distance from the suspected site; the pain 
occurs not at the point of pressure but at the 
point of fracture. 

Reduction. — The assistant grasps the leg 
at the knee, the surgeon the foot, seizing the 
foot with one hand and the heel with the 




Fig. 151. — Cloth cut to fit the limb and gored at the ankle in order to be more easily- 
adjusted to the malleoli when it is soaked with plaster. (Lejars.) 



other; or two assistants may make the necessary traction while the 
surgeon manipulates the fragments. 

What is the test of good coaptation ? The crest of the tibia forms a 
continuous line without projections or depressions. This line pro- 
longed strikes the first metacarpal space. The internal surface of the 
tibia is smooth and uniform. With the foot at a right angle, a line 
dropped from the anterior superior iliac spine to the inner border of 
the great toe touches the inner border of the patella. 

Dressing. — This will vary somewhat, depending upon the situation 



PLASTER SPLINT FOR THE LEG. 



209 



and tendency to displacement. In the simple case of fracture of the 
shaft of the tibia, following the counsel of Stimson (Fractures and Dislo- 
cation, page 381 et seq.), it is best to put the patient to bed with the 
limb in a Volkmann splint for about a week until the swelling has sub- 
sided, and then to encase it in plaster-of -Paris. Immediate applica- 
tion of the plaster-of-Paris is objectionable because it cannot be deter- 




FiG. 152. — Plaster splint applied and fixed with roller plaster bandage. Note manner 
of supporting limb and applying roller. (Lejars.) 



mined from the first whether the swelling will increase or diminish. 
The two dressings may be combined by applying a plaster splint from 
the first. 

Lejars describes the construction of such a splint. He meas- 
ures from the middle of the thigh dowm to the heel and up the sole to 
the toes, and this will be the length of the sixteen layers of crinoline 
from which the splint is to be made. Take the circumference of the 
thigh, the knee, the middle of the leg, the ankle, and transfer the 
14 



2IO 



FRACTURES. 



measures to the crinoline which was cut wide enough in the first place 
to encircle the thigh. Connect the ends of these cross measurements 
with a chalk line and in this manner one forms a rough outline of the 
limb, and the bandage is cut accordingly. Some prefer to apply the 

material to the sound limb and 
mark it off in that way. 

Opposite the ankle a notch 
should be cut in the dressing, 
running toward the heel, that the 
dressing may be more readily fitted 
(Fig. 151). This is soaked with 
liquid plaster and applied while the 
extension and counterextension are 
maintained and the foot fixed at a 
right angle. This tension must 
not be relaxed until the plaster has 
hardened. The dressing is com- 
pleted by applying a roller bandage 
(Fig. 152). 

Oblique fractures, which are hard 
to hold, are likely to be near the 
lower end, for the quadriceps ex- 
tensor pulls the upper fragment 
forward, and the gastrocnemius 
pulls the lower fragment backward. 
The special form of dressing which 
Scudder recommends for this form 
of fracture is made by a combina- 
tion of plaster and adhesive strips. 
The adhesive strips are applied as 
indicated (Fig. 153). A thick rod 
of sheet w^adding is applied to the 
sole of the foot, and a plaster 
bandage applied from the toes to above the knee. A buckle look- 
ing upward is incorporated in the plaster just above the level of the 
knee. A slit is left in each side at the ankle for the lower extension 




Fig. 153. — Plaster traction splint: a, Ap- 
plication ot adhesive-plaster extension 
strips; b, plaster bandage allowing exit of 
extension straps. Note space left below 
the sole to allow for effective traction and 
buckles to which the upper extension is 
attached. (Scudder.) 



POTT'S FRACTURE. 



211 



strips to come through. When the plaster has hardened, the upper 
extension strips aie fastened in the buckles and the lower extension 
strips pulled out through the slits and drawn tight around the foot 
piece after the wadding at the sole has been removed. The purpose 
of this arrangement is to maintain extension. 

Whatever form of dressing is used the limb must be watched to 
see that no displacement occurs. While a simple fracture usually 
firmly unites within six wxeks, those which have been hard to keep 
reduced will remain weak much longer. As soon as there is sufficient 
union to prevent displacement, 
then massage should be begun 
and continued till the limb's 
functions are restored. 

PoWs Fracture. — Fracture of 
the fibula with eversion and 
abduction has a character of 
its owm. As Stimson remarks, 
the diagnosis can usually be 
made at a glance (Fig. 154). 
Three points of tenderness on 
pressure are constant and char- 
acteristic: one in the groove 

between the tibia and external malleolus; another at the base of 
the internal malleolus; the third over the outer aspect of the 
fibula marking the point of fracture. Marked ecchymosis 
appears beneath the external malleolus and sometimes beneath the 
internal. 

Reduction. — Grasp the foot in one hand, the heel in the other, 
and while the leg is steadied by the assistant, draw the foot forward and 
inward. If this does not entirely succeed, the fragments may be 
pressed into place. AVith the foot at a right angle and the malleoli in 
their normal relations, the dressing is applied. This dressing, to quote 
Stimson further, is preferably a posterior and lateral plaster splint 
although the plaster cast may be used. 

The plaster splint may be made from twelve to thirteen layers, cut 
from a four inch plaster roller. The posterior splint should be long 




Fig. 



-Pott's fracture. 



212 



FRACTURES. 



enough to extend from the toes along the sole and up the calf nearly 
to the knee (Fig. 155). The lateral one should begin just in front of 
the external malleolus, pass over the dorsum of the foot to the inner 
side, under the sole and up along the outer side of the leg to the same 





Fig. 155. — Posterior splint applied. 
(Stimson.) 



Fig. 156. — Lateral splint 
applied, (Stimson.) 



height as the posterior (Fig. 156). They are snugly molded and 
bound to the limb while still wet, with a roller bandage. 

In the meantime, till the plaster sets, the reduction must be main- 
tained. 



FRACTURE OF THE SCAPULA. 



213 



Dupuytren's splint is often of great service in this fracture, especially 
as a temporary dressing. It consists of internal lateral splint, well 
padded over the ankle and which extends from above the knee and 




Fig. 157. — Dupuytren's splint. Temporary dressing for Pott's fracture. 

projects beyond the foot. It is held in place by a bandage at the knee 
and above the ankle. The foot is then put in abduction at right angle 
to the leg and secured to the splint bv a third bandage (Fig. 157). 



FRACTURE OF THE SCAPULA. 

Fracture of the neck of the scapula might be mistaken for fracture 
or dislocation of the humerus (Fig. 158). The head, however, can be 
felt to rotate, which it would not do 
in dislocation. The deformity dis- 
appears on lifting the arm forcibly 
upward with the elbow flexed. 

In the case of fracture of the 
surgical neck with overriding, the 
arm is shortened. In case of frac- 
ture of the scapular neck, the arm 
is lengthened. 

Generally speaking, the diagnosis 
of any fracture of the scapula is to 
be made from crepitus, abnormal 
mobility, local tenderness, and more 
or less complete loss of certain func- 
tions. 

Treatment. — The flexed elbow should be well supported by a sling 
and the arm fixed at the side. Massage will relieve the pain and hasten 
repair. 




Fig. 158. — Fracture of the neck of 
the scapula. 



214 



FRACTURES. 



FRACTURE OF THE PELVIS. 

Fracture of the pelvis may be suspected from the character of the 
injury, which is usually a fall or a crush. The diagnosis is to be con- 
firmed by external palpation of the ilium, pubes and ischium on each 
side, and by careful rectal and vaginal examination. Disturbance 
of normal relations, tenderness on pressure, crepitation perhaps, and 
difficulty in walking indicate fracture (Fig. 159). 

The treatment in uncomplicated cases is quite simple, rest in bed 




Fig. 159. — Fracture of the pelvis through the obturator foramen and dislocation 
at the sacroiliac joints. (Moullin.) 



and some kind of pelvic immobilization represent the elements of 
relief. It is quite different if there are complications. 

If a catheter cannot be passed (and this should always be tried), 
it will be necessary to do an external urethrotomy for the ruptured 
urethra. If the catheter finds the bladder empty and ruptured, a lap- 
arotomy is imperative. If the exact complications cannot be deter- 
mined and yet shock, pain, and increasing abdominal tension, with 
signs of sepsis, point to a lesion of bladder or rectum, the abdomen must 
be opened, and the visceral injury found and repaired. 



TREATMENT OF COMPOUND FRACTURES. 



215 



COMPOUND FRACTURES. 

Every compound fracture, whether the skin wound be large or small, 
increases the danger over simple fractures both with respect to function 
and even life. 

The outcome, as has so often been said, depends largely on the 
jirst treatment. The indications are various and depend upon the 
amount of fragmentation, the degree of destruction of the soft parts and 
the injury to the blood vessels. 

It is necessary to divide these injuries into several clinical groups: 
(See Lejars Chirurgie d'Urgence, p. 1017 et seq.) 

I. Compound comminuted fracture with no injury to the vessels, 




Fig. 160. — Compound fracture of tibia. (MouUin.) 

with slight injury to the sojt parts, and small skin wound is most commonly 
seen in oblique fractures of the tibia (Fig. 160). The break in the 
skin is slight and yet it is actual and must be regarded as infected. 
Do not be satisfied with merely washing the skin, or applying a 
simple occlusive dressing. This may be sufficient in the case of gun- 
shot wounds; the circumstances may permit of no further treatment; 
and many cases will get well with nothing more, but that is significant 
of only one thing — that by good luck the wound was not infected 
Whether the wound is or is not infected, one can never tell. He must 
await the eventualities. Therefore, that chance may not enter in, one 
must exercise the same care as if he were certain the germs were there. 
A general anesthesia is usually not necessary. Begin by carefully ster- 
ilizing the surface about the wound. Scrub with soap and water, wash 



2l6 FRACTURES. 

with ether and then with alcohol and finally with bichloride. Enlarge 
the wound sufficiently that it may be irrigated with hot sterile water, or 
normal salt solution. Carefully clear out all debris with as little 
injury as possible to all the tissues concerned. When the cleansing is 
complete, if circumstances are favorable, the wound is sutured and 
drainage employed. Occasionally, it may be closed completely with- 
out drainage. Sometimes it must be left wide open, packed with sterile 
gauze and bandaged. 

Adjustment and Immobilization. — Reposition requires great care and 
it must be exact. Unless the fragments are extremely difficult to hold 
in place, requiring wiring, the limb may be immobilized with a plaster 
splint, leaving an opening sufficient for the inspection of the wound. 

Gangrene is little to be feared unless, indeed, the bandages are 
carelessly applied, interfering with the circulation. 

Immobilization is the best method for relieving pain. Carry out a 
careful disinfection, a careful adjustment of the fragments, a careful 
immobilization in a good position, and one may confidently expect in 
such cases an excellent result-. 

2. Compound Fracture with much Comminution and Great Destruction 
to the Soft Parts, little Injury'to the Blood Vessels. — A general anesthesia 
will be necessary. Prepare the field as before and flush out the wound 
cavity with hot sterilized water. Trim away the fragments of fascia 
and muscle, but in this do not be too radical. Such of these shreds 
as retain their blood supply can help later to fill the wound. Especially 
do not remove with too free a hand the fragments of the bone. Only 
such fragments as are completely isolated and deprived of their peri- 
osteum, are to be extracted so that later they may not play the part of 
foreign bodies (Fig. i6i). 

The second step consists of reposition and adjustment, often with 
difficulty accomplished and many times requiring wiring or suturing. 
The wound may be sutured but must be drained. More important 
even than accurate coaptation in these cases is continuous extension; 
for that reason the fixation dressing must be given special attention. 
If no fever arises, leave the dressing undisturbed for eight to ten days. 
The danger from infection is then passed and the immobilization and 
extension may be continued as long as necessary. 



TREATMENT OF COMPOUND FRACTURES. 



217 



3. Compound Fracture, Obviously Injected. — You see the case per- 
haps some days after the injury. It has been neglected. Marked 
inflammation is present. You are confronted by the possibilities of 
phlegmon or tetanus. These may develop with the greatest rapidity 
and continue uninterruptedly to death. 

How shall one act in the presence of these filthy or already infected 
or inflamed fractures ? To amputate would have been in pre-antiseptic 









B^ 








VBk^ 




i 


^ 


^ 




^ 
















i 


r 





Fig. 161. — Compound fracture and dislocation at the wrist. Hand saved. (Scudder.) 



days the proper procedure, but not today and especially not in the 
recent case. 

Enlarge the wound freely. Remove the coarsest dirt by irrigation 
and then patiently and perse veringly, wiping with sterile compresses 
while flushing, complete the toilet of the individual tissues, one at a 
time. The fragments of bone must be separated and the remotest nook 
of the wound sought out, that the cleansing may be complete. Uo not 
spare time or patience. If the projecting fragment of hone is saturated 
with dirt, manifestly devitalized, resect it, not transver.^ely, however, after 



2l8 FRACTURES 

the manner of an amputation, but following some type of plastic 
operation which will diminish, as much as possible, the loss of bone and 
consequent shortening of the limb. 

Finally the wound is flushed with peroxide of hydrogen and wrapped 
with sterile gauze saturated with the same solution. With the frag- 
ments coapted as much as may be by simple manoeuvres, though one 
cannot hope to achieve much in this respect, the drainage is applied 
and must be ample. The limb is put at rest and with anxiety the out- 
come is awaited. The issue may be fortunate. General and local 
infection may be successfully combated and later the bone union may 
be secured. 

On the other hand, should general infection be imminent or gangrene 
ensue, or the limb be from the first manifestly destroyed, there is no 
choice but to amputate. 

COMPOUND FRACTURE ABOUT THE ANKLE AND 
FOOT. 

Fractures of this variety are frequent; always serious; and the prog- 
nosis more or less uncertain, depending upon the degree of infection 
and destruction of the soft parts 

Suppose a fracture of the inner malleolus : the soft parts are widely 
separated, the joint cavity exposed, the astragalus dislocated. Such 
an injury must be as conservatively treated as an abdominal wound. 
Under no circumstances must the wound be explored with unclean 
fingers or without careful cleansing of the field. Only after all the 
preparations for definite treatment are made, is the wound to be ex- 
amined. If transportation is necessary, a temporary splint is provided, 
but at least do not cover the wound with a dirty handkerchief. If 
there is much hemorrhage, circular constriction of the leg about the 
knee will temporarily suffice. 

The first dressing will determine the future of the limb, perhaps 
even the life or death of the wounded. The whole foot and the lower 
half of the leg are most carefully disinfected and the fracture and joint 
cavity irrigated wdth hot sterile water, exposing every nook and corner 
in order to flush out foreign bodies, splinters of bone and clots of blood. 



TREATMENT OF COMPOUND FRACTURES. 219 

In this case, merely chosen for example, the destruction of tissue is 
unusually light. After the cleansing, 'replace the parts, leave one or 
two drains in the partly sutured wound, bandage amply and place 
the limb at rest. 

The situation is less simple where there is much destruction of tissue, 
as in the case where the ankle is crushed. 

Begin with hot irrigations. Do not fear to enlarge the wound freely. 
It is of great importance that one be able to determine definitely the 
conditions in the wound and to see what he is doing. 

You may find large fragments deformed and overlapping. Try 
to replace them and often you will be thus enabled to restore the con- 
tour of the joint. To retain these fragments, wiring or nailing the 
fragments, if in a position to carry it out, will be an almost indispen- 
sable aid. 

Another cdse: The epiphyses are reduced to fragments of various 
sizes and forms. In irrigating, they flow away with the solution, so 
loosened are they. The rest hang by a mere shred. 

Reposition is here useless. The wreck is too great. You must 
proceed to do an atypical resection. Do your best to spare the malleoli 
or at least two processes which will serve to prevent lateral dislocation 
when the joint is healed. 

After this operation insert two drainage tubes, one on either side and 
if there is considerable oozing, add an aseptic tamponade. 

The prognosis is worse if injection has developed and there is fever, 
redness and swelling in the limb. Amputation will be the measure of 
last resort and yet do not amputate until free opening has again been 
tried. Irrigate with peroxide. The removal of dead bone, etc., is 
followed by deep drainage but this must be done without delay. It 
is not union, or consolidation, or function of the limb which is the chief 
concern. It is infection against which all the forces of antisepsis are 
marshalled. 

Osteomyelitis or myelitis is the contingency feared. In such a case, 
do not employ a typical amputation or resection but an atypical one, 
removing only such tissues as must be removed, and later when the 
infection has disappeared, the necessary operations may be done. 



CHAPTER XIV. 

INJURIES TO JOINTS. 

Dislocations ; Compound Dislocations ; Open Wounds ; Con- 
tusions; Sprains. 

DISLOCATIONS. 

Shoulder Joint. — Of all the joints, the shoulder is by far the most 
frequently dislocated. Of these dislocations, there are several forms, 
and yet only one variety is likely to be met with by the general practi- 
tioner — the suh-coracoid. A clear conception of the conditions and 
of the manoeuvres necessary to a reduction, presupposes a very definite 
notion of the anatomy of the joint. 

Recall the relation of the acromion and coracoid processes to the 
glenoid fossa, to the head of the humerus and to the capsular liga- 
ment; the relation of the long head of the biceps to the joint and the 
attachments and actions of the various muscles surrounding the joint, 
particularly the sub-scapularis, the spinati, the pectoralis major; and 
the relations of the axillary vessels and nerves. 

However simple a case may appear, do not begin any manoeuvre 
until a complete diagnosis has been made. 

Diagnosis. — Begin by inspection. The patient is in evident pain; 
his head is inclined to the injured side and he supports the injured 
member with the other hand; the shoulder is flattened, the rounded 
prominence of the deltoid has disappeared and the acromion projects; 
the elbow is abducted and the patient is unable to bring it down to the 
side. 

Palpation reveals the axis of the humerus pointing to the middle of 
the clavicle; the examining finger can be pushed under the acromion 
where the humeral head should be. The humeral head itself may be 
felt below or to the inside of the coracoid, and rotates with slight ro- 
tation of the arm. 

220 



REDUCTION OF THE SHOULDER JOINT. 221 

The fingers in the axillary space feel the rounded head of the hu- 
merus projecting inward, more noticeably when the arm is slightly 
abducted. 

This question arises: "Is it a case of simple dislocation, or is it 
complicated by a fracture of the upper end of the humerus, of the great 
tuberosity, or the rim of the glenoid fossa?" "Have the arteries or 
nerves been injured?" You must test particularly for laceration of 
the circumflex nerve. Do this by pin pricks over the deltoid; if the 
skin is insensitive, forecast paralysis and atrophy of the deltoid, and 
thus anticipate and disarm censure. 

Reduction. — (Lejars.) The method of Kocher seldom fails, if 
properly applied, and if the various movements are modified to suit 
the individual case. Its purpose is to put the head of the humerus in 
the position at which it left the capsule. Through the relaxed tear, the 
head is then to be levered into the socket. 

Seat the patient in a chair facing a little to one side. Let a 
strong and able assistant, standing behind, seize the patient's shoulder 
firmly and make pressure downward and backward. Place yourself 
before the dislocation, and seizing (in the case of the left arm) the fore- 
arm at the elbow with the left hand, and the wrist with the right hand, 
direct the patient to hold the head up and look straight ahead. 

First Stage: Flexion, Adduction. — The elbow is flexed and then 
gradually adducted until it touches the body, the wrist held firmly 
meanwhile. The elbow is now pushed backward beyond the axillary 
line — the first stage is not complete without this. Neglecting this part 
of the first manoeuvre is a frequent cause of failure. Do not get in too 
great a hurry. Remember that the larger part of the resistance is due 
to the muscles and that they yield only gradually. Too sudden and 
too violent traction on them augments the pain and their resistance. 
To pause a little now, gives them time to relax (Fig. 162). 

Second Stage: External Rotation. — Hold the elbow fast and flexed 
at a right angle, and now with your right hand, swing the forearm 
outward and backward until it lies in the transverse vertical plane 
of the body (Fig. 163). Its axis lies directly in front of you. Perform 
the manoeuvre cautiously and smoothly. Again pause until the muscles 
are relaxed. Do not be alarmed by the snapping distinctly heard 



222 



INJURIES TO JOINTS. 



in the movement. One may follow the movement of the bulging 
head of the humerus with the eye. Occasionally reposition occurs at 
the end of this movement, if it has been carried out methodically, or at 
least at the beginning of the third stage. 




Fig. 162. — Reduction of shoulder. First stage: Flexion; adduction; elbow a little 
posterior to the axillary line. 



Third Stage: Elevation. — Maintaining flexion and external rotation, 
next lift the elbow upward and forward — upward and forward exactly 
— do not permit the elbow to move outward. Abduction will spoil the 



REDUCTION OF THE SHOULDER JOINT. 



223 



manoeuvre (Fig. £64). Lift upward and forward till the arm reaches 
the horizontal — a sudden snap indicates that the head has slipped into 
the socket. 




Fig. 163. — Reduction of shoulder. Second stage: External rotation until forearm 
stands at right angle to body. 



Fourth Stage: Internal Rotation. — Proceed now rapidly to swing the 
forearm inward and across the chest until the hand rests on the oppo- 
site shoulder (Fig. 165). The movement is made rapidly but with no 



224 



INJURIES TO JOINTS. 



great force. This latter holds good with respect to all the movements. 
It must be observed that the surgeon's hands do not change their hold 
at any stage of the reduction. 




Fig. 164. — Reduction of shoulder. Third stage: Elevation while maintaining 
external rotation. 



If these manoeuvres fail, repeat them in the same order, using a little 
more force in the second and third stages and pausing a little longer 
at the end of a stage. 

In the sul-claviadar form also, this manoeuvre will succeed, but 



REDUCTION OF THE SHOULDER JOINT. 



225 



should be modified to this extent: prolong the second stage two or 
three minutes, using more force to obtain external rotation and the 
backward position of the elbow. In this wise, the muscles are relaxed 
more completely. Without changing the external outward rotation, 
the elbow is lifted upward and forward as before. 




Fig. 165. — Reduction of shoulder. Fourth stage. Internal rotation. 

Not less efficient in certain cases of sub-coracoid dislocation, is the 
method of Mothe, or traction in extreme abduction. It is also applicable 
in all other forms of inward and downward dislocation. 
15 



226 



INJURIES TO JOINTS. 



In this procedure, counterextension is indispensable. A long towel 
will serve. It encircles the injured shoulder, passing under the arm 
pit, and the two ends cross the back toward the sound side. While the 




Fig. 1 66. — Reduction of shoulder. Traction with high abduction. The axis of the humerus 
should be in line with the spine of scapula. Assistant steadies the shoulder. 



assistant makes forcible counterextension, the operator manipulates the 
arm. It is best that he stand on a stool or chair if not tall enough to 
make good traction upward. Now seize the arm above the elbow and 



REDUCTION OF THE SHOULDER JOINT. 



227 



the forearm near the wrist (Fig. 166). Flex the elbow. Next elevate the 
arm by extreme abduction until it is in line with the spine of the scapula. 
The arm, you must observe, does not reach the horizontal merely, it 
is elevated beyond that level. This is of the greatest importance. 
With the arm thus in extreme abduction, next make strong traction in 




Fig. 167. — Reduction by high abduction and traction. Note inannt 
the assistant steadies the shoulder. (Lejars.) 



m which 



that direction (Fig. 167). Assistance in traction may be necessary; 
or one may confide the traction to an assistant, while with the thumbs, 
one pushes against the humeral head in the axillary space. 

If this does not succeed, begin the second stage: 

Depress the arm rapidly and smoothly, letting the point of the 



228 



INJURIES TO JOINTS. 



elbow pass in front of the chest, all the while maintaining traction. 
This method occasionally fails for these reasons: 

(i) Traction with high abduction is not long enough continued. 




Fig. i6i 



-Chipman's method of reducing dislocated shoulder. First stage. 
(International Journal of Surgery.) 



The arm is depressed before the head has been sufficiently elevated 
by traction. 

(2) The arm is lowered too slowdy. 

In neglected cases or in the very muscular, general anesthesia may 
be indispensable whatever the method, but force must then be em- 



REDUCTION OF THE SHOULDER JOINT. 



229 



ployed with still greater care, and it must be borne in mind, too, that 
incomplete anesthesia here is as dangerous as it is useless. The partic- 
ular danger of this method is laceration of the axillary structures. 





f^^^^K 


inl^ 


M^P .1 


KJJ\ 


\ .>! 



Fig. 169. — Chiprpan's method of reducing dislocated shoulder. Second stage. 
(International Journal of Surgery.) 



How long after the injury reduction may be attempted cannot be 
determined by any rule, but by the conditions in the individual case. 
Chipman, of New London, Connecticut, suggests a method which 
must prove of value, especially to the doctor compelled to act without 
assistance. 



230 



INJURIES TO JOINTS. 



He describes his method thus (Int. Journal of Surgery, November, 
1906): Stand facing your patient. Gradually raise the dislocated 
arm to a horizontal position and place it on your shoulder with forearm 
flexed on your back. Direct the patient to pass the well arm under 
your arm and grasp the wrist of the injured arm with the well hand. 
Thus the patient's arms encircle your body, the injured one passing 
over one shoulder, the sound passing under the other (Fig. 168). 

Second Stage. — Now direct the patient to sag downward, and the 
weight of the body drags the head of the humerus outward and up- 
ward, when you can easily return it to the glenoid cavity with your 




Suh-coramd 



Fig. 170. — Dislocation of shoulder. (Walsham.) 

hands (Fig. 169). The dislocation is so easily and expediously reduced 
that even the surgeon himself is surprised. There is the least possible 
additional injury, the least possible pain; there is no need of an assistant 
or an anesthetic. 

SUB-GLENOID DISLOCATION. 

This variety is always the result of forcible abduction of the humerus, 
the tear in the capsule falling below the glenoid cavity, and the head 
of the humerus remaining fixed there (Fig. 170). 

The diagnosis is to be made from the symptoms already described 



REDUCTION OF SUB-GLENOID DISLOCATION. 



231 



for the sub-coracoid form, the only difference being that the elbow 
is further from the chest, the flattening of the shoulder more pronounced, 
the head of the humerus more readily felt in the axilla (Fig. 171). 




Fig. 



:7i. — Reduction of a sub-glenoid dislocation. Second stage. Gradual 
elevation with constant traction. 



The reduction may be affected by Kocher's method, but perhaps 
the best method is that of extreme abduction with traction, which has 
already been described. The patient may be seated, but often must 
recline, for the weight of the pendent limb may be very painful. The 



232 



INJURIES TO JOINTS. 



injured member is grasped above the elbow with one hand, below the 
wrist with the other, flexed, slowly raised to form an obtuse angle with 
the chest. In this position strong traction and countertractipn are to 




Fig. 



-Reduction of sub-glenoid dislocation. Third stage. Traction with 
high abduction and pressure on the humeral head. 



be made. Usually this succeeds though it may help to press the head 
into place (Eig. 172). If traction and pressure are not sufficient to 
effect reduction after the muscles have been thoroughly relaxed, the 
arm is to be depressed as before described. 



AFTER TREATMENT OF SHOULDER DISLOCATION. 233 

Subspinous Dislocation. — In this case the shoulder is flattened in 
front and the examining finger finds a marked depression between the 
tip of the acromion process and the coracoid. The elbow is carried 
slightly forward and the arm rotated inward. The head of the 
humerus can be felt below the spine of the scapula. 

Reduction. — General anesthesia is usually necessary. Grasp the 
arm above the elbow; slightly abduct the arm; slightly increase the 
inward rotation (never rotate outward); make traction in a direction 
downward and forward. Pressure forward on the head is helpful. 

AFTER TREATMENT OF SHOULDER DISLOCATIONS. 

The task in any form of dislocation does not end with reduc- 
tion. There is still the duty to restore usefulness as completely 
as possible, and to that end the subsequent care must be minutely 
regulated. The inclination is to immobilize the joint too completely 
and too long, fearing a recurrence of the dislocation. This enforced 
rest combined with injury is liable to produce atrophy of the muscles, 
stiffness of the joint, and protracted loss of function. The indications 
for. after-treatment are various, depending upon clinical conditions. 

(A) An uncomplicated, easily reduced dislocation in a healthy strong 
adult: 

Begin by immobilizing the shoulder but take care that after three 
or four days of complete rest, massage and passive motion shall be 
begun. The joint is cautiously put through all its motions, the deltoid, 
and pectoralis major and the scapular muscles carefully massaged; 
a daily seance gradually prolonged. 

In the interval the arm is bandaged but gradually the dressing is 
relaxed, and after a week, movement left quite free. In two weeks of 
such treatment the function may be entirely restored. 

(B) The case was complicated with injury to the soft parts, was with 
diS&culty reduced, and only after a number of attempts; it is likely that 
the capsular ligament was extremely lacerated. 

Under such circumstances not only passive displacement but actual 
dislocation is to be feared. Immobilize the joint with a Mayor sling 
or Velpeau bandage and let it so remain a week. But this will not 
prevent massage over the shoulder after four or five days. Do not })ro- 



234 



INJURIES TO JOINTS. 



long the fixation, remembering that a dislocation accompanied by great 
violence furnishes the condition most favorable to adhesions and 
weakness, and against these evils, we have no remedies but massage 
and gymnastics, which must be early begun and long continued. 



DISLOCATION OF THE LOWER JAW. 

This accident, which may happen at most unexpected times, when 

yawning or laughing, for instance, 
might be confused with certain 
fractures of the inferior maxilla. 
The opened mouth, the loss of 
power to close it, are characteristic 
(Fig. 173). The reduction is 
usually easy. Both sides may be 
reduced simultaneously. Wrap 
the thumbs; you have to deal with 
the powerful muscles of mastica- 
tion, which, when the dislocation 
is reduced, are likely to close the 
jaws with much force. 

The thumbs passed into the 
■^^ mouth press downward and back- 
^ ward on the molar teeth; at the 
same time, the fingers hooked under 
(Aiouiiin.) the chin pull upward. In the mus- 
cular, considerable force is required, 
jaws should be moved only slightly for several days. 




DISLOCATION OF THE ELBOW. 

Dislocation of the elbow, which occurs with considerable frequency, 
especially in children, nearly always assumes the form of backward 
displacement. 

Diagnosis. — The elbow is increased in thickness antero-posteriorly. 
The olecranon is unduly prominent. The flexure of the joint is de- 
pressed. Where the head of the radius should be there is a depres- 



REDUCTION OF THE ELBOW JOINT. 



235 



sion. The olecranon is abnormally prominent. Compare the rela- 
tion of the olecranon to the inner condylar lines on the two sides. 
Flexion is quite painful and practically impossible. 




Fig. 174. — Reduction of the elbow joint. Traction with gradual flexion combined 
with pressure forward on the olecranon. 

If the diagnosis is doubtful, as it often must be when swelling is 
great, one thinks of supracondylar fracture. But in the case of frac- 
ture, the relation of the olecranon to the intercondylar line is unaltered. 
The humerus is shortened. The deformity disappears with traction. 



2^6 INJURIES TO JOINTS. 

Reduction. — (A) Standing on the injured side, seize the arm above 
the elbow with both hands, and as an assistant makes traction on the 
forearm, steady the arm and press with both thumbs on the olecranon. 
The traction is made at first in the direction of the long axis, but as 
the limb yields, the forearm is rapidly flexed — continuing the trac- 
tion and pressure. By this means reposition is usually quite easy. 
(Fig. 174.) 

(B) Method of forced extension: 

Traction and countertraction as before, except that the traction 
which begun in the direction of the long axis of the forearm and pro- 
duced flexion, now produces hyper-extension. In the meantime, press 
on the olecranon and the head of the radius. In this w^ay, one will 
sometimes succeed, but do not forget this method is available only for 
those who have supple joints. 

(C) Method of Astley Cooper: 

The patient is seated on a chair — you place yourself on the side 
opposite the injured elbow. It is the right, for example, stand upon 
the left side and place a foot upon the chair. Get the bend of the el- 
bow over the knee. Steadying the humerus wath one hand, draw on 
the flexed forearm with the other, at the same time flexing the elbow 
over the knee. 

Generally speaking, however, if the first method fails, it is better 
to give a general anesthetic, with which the chief difficulties disappear. 

Lateral dislocations are usually replaced without much trouble by 
pressure combined with extension. 

After-treatment. — This must be begun even earlier than for the 
shoulder — ^massage and passive motion — else a stiff joint is very likely 
to follovv. 

DISLOCATION OF THE THUMB. 

This accident, apparently simple, presents some peculiarities, which 
must be borne in mind. 

These displacements at the metacarpo-phalangeal joint, are classi- 
fied as incomplete, complete and complicated, depending upon the 
relation which the articular surfaces assume and upon the disposition 
of the sesamoid bone (Fig. 175). Incomplete dislocations leave the 



REDUCTION OF DISLOCATIONS OF THE THUMB. 



237 



Fig. 



^ r^ 



f^ 



y 



articular surfaces in slight contact; complete dislocsitions find the artic- 
ular surfaces at right angles, the phalanx 
standing upon the dorsum of the meta- 
carpal (Fig. 176); and, if in addition to 
this, the torn anterior ligament and sesamoid 
bone, in attempt at flexion, are wedged be- 
tween the articular surfaces, the dislocation 
is said to be complicated, a condition difficult 
to manage (Fig. 177). Since this condition is 
produced by maladroit attempts at reduction 
of the complete dislocation, it is especially 
desirable to understand the man euvres. 

Whether the dislocation be complete or 
incomplete, never attempt reduction by 
flexion. That is the thing to be avoided. 
Seize the thumb and slightly bend it still 
further backward, at the same time pushing 
the base of the phalanx obliquely down- 
ward and forward. Directly the phalanx 
will be felt to slide over the head of the metacarpal into its place. 

Complicated Dislocation. — (Lejars.) Employ general anesthesia 




—Complete dislocation 
of thumb. (Moullin.) 



fCs^"-^ 




'S 




Fig. 176. — Complete dislocation 
of thumb. (Moullin.) 



Fig. 177. — CompHcated dislo- 
cation of thumb. (Moullin.) 



Only the most carefully regulated manoeuvres will succeed. Do not 
attempt the reduction unless the various steps are clearly in mind. 



238 



INJURIES TO JOINTS. 



(i) Make traction on the digit in the direction of its axis until it is 
as long as normal. 

(2) Seizing the thumb between forefinger and thumb in such 
manner that your thumb presses on the dorsal surface of the dislo- 
cated joint, bend it backward until it stands perpendicular to the meta- 
carpal, or even further. The object is 
to put the thumb in the position of 
uncomplicated dislocation and thus 
disengage the sesamoid bone. 

(3) Still holding it at that angle, push 
the base of the phalanx forward. 

(4) Having pushed the phalanx as 
far forward as possible in this man- 
ner, begin suddenly to flex it, in the 
meantime keeping the last phalanx 
extended and do not cease to push 
forward while flexing. 

If failure attends two or three at- 
tempts, do not persist; proceed to 
operate. 

Dislocations of the fingers should be 
treated in the same manner — never 
begin by flexing. 

Reduce by first bending the finger 
backward and then pushing the base 
of the phalanx forward. In every case 
Fi9-.;78.— Backward dislocation, dorsum the Durpose is to reproduce in reduc- 

ilii ; shortening, inversion. (MouUin.) r r r 

tion the movements of dislocation. 




DISLOCATION OF THE HIP. 



These accidents are always serious, and yet are comparatively rare. 
Of the different forms of luxation of the femoral head, the backward 
on the dorsum ilii is by far the most frequent (Fig. 178). 

Diagnosis. — The thigh is adducted, rotated inward, and practically 
immovable. The leg is apparently shortened, the knee slightly flexed. 



REDUCTION OF THE HIP JOINT. 



239 



The trochanter rests above the line drawn from the spine of the ilium 
to the ischial tuberosity. The femoral head may be felt under the 
gluteal muscles on the dorsum ilii. 




\FiG. 179. — Reduction of the hip. Flexion of the knee. Gradual flexion of 
the hip with traction on thigh. 



Reduction. — General anesthesia is often necessary. Lay the patient 
on a-pallet on the floor. A strong assistant, pressing on the iliac spines, 
immobilizes the pelvis. 

Fist Movement: Flexion of Thigh, — Grasp the thigh above the knee 



240 I^7URTES TO JOINTS. 

with one hand and with the other, the leg, and gradually tiex the hip 
and knee. Flex the hip to a right angle. 

Second Movement: Traction on the Flexed Femur. — When the hip 
is flexed at a right angle, begin traction, maintaining that angle. Do 




Fig. 1 80. — Reduction of hip. Third stage. External rotation. 
Hip strongly flexed. 

not be afraid to use force. This is the most important manoeu\Te. 
Properly applied, that is to say, powerful traction on the hip bent at a 
right angle, the effort will often be rewarded by a sudden snap,Vhich 
indicates that the femoral head has returned to its socket (Fig. 179). 



ISCHIATIC DISLOCATION. 



241 



Third Movement: External Rotation with Abduction.— Vtrsisting in 
the traction, the resisting muscles are felt to yield. Now carry out 
the final manoeuvre, which should guide the head over the rim of the 
acetabulum into place. Continue traction to some extent, but rotate 





Fig. 181. — Dislocation of hip 
backward into the sciatic notch. 
Leg shortened, foot inverted. 
(MouUin.) 



Fig. 182. — Forward dislocation: 
sub-pubic; extension, eversion. 
(MouUin.) 



the thigh outward and at the same time abduct. All the other methods 
proposed are but modifications of this (Fig. 180). 

ISCHIATIC DISLOCATION. 

Diagnostic points: Adduction, inward rotation, marked flexion of 
both knee and hip (Fig. 181). 

Reduction. — By the same method as the dorsum ilii. Do not begin 
the final movement of abduction and external rotation too soon. 
16 



242 



INJURIES TO JOINTS. 



SUB-PUBIC DISLOCATION. 

Diagnostic points: Compared with the ischiatic an opposite con- 
dition of affairs exists — abduction, external rotation and extension. 
The great trochanter can not be located (Fig. 182). 

Reduction. — Flexion is here illusory, and equally so, blind traction. 
Slightly lifting the extended limb, abduct it 
as far as possible; while abducting continue 
to lift. The head rolls down toward the 
obturator foramen, and finally the thigh 
stands vertically. Now adduct and rotate 
inward. 

OBTURATOR DISLOCATION. 

Diagnostic poiif "^^Fhe hip is flexed, ab- 
ducted, and rotateu v^utward (Fig. 183). 

Reduction. — Flexion of hip, traction on 
flexed thigh, adduction, inward rotation. 

DISLOCATION OF THE KNEE. 

This accident is infrequent, easy of diag- 
nosis, and comparatively easy to reduce. 

General anesthesia is frequently neces- 
sary. Two assistants are needed, one for 
traction on the leg, and one for countertrac- 
tion on the thigh, while pressure is applied 
at the joint. 

One must be concerned here with the 
condition of the blood vessels. Suppose 
there is no pulse at the ankle, the popliteal space is evidently filled 
with blood. Under these circumstances apply a tourniquet, and, 
under rigid antisepsis, open up the space by a longitudinal incision, 
turn out the clots, ligate the torn vessels. Remove the tourniquet, 
complete the hemostasis, and sew up the wound. The limb is band- 
aged in cotton, elevated, and kept warm. Time alone can tell whether 
or not the circulation will be restored and gangrene averted. 




Fig. 183. — Downward disloca- 
tion. Obturator. (MouUin.) 



DISLOCATION OF THE ANKLE JOINT. 243 

DISLOCATION OF THE SEMILUNAR CARTILAGES. 

This is an injury likely to be forgotten in making a diagnosis of 
disabilities of the knee. 

The internal semilunar cartilage is much more likely to be in- 
volved, the accident usually occurring in this manner: the individual 
attempts to turn suddenly while the knee is flexed. The cartilage, 
either as a whole ot, more often, a part, projects to the outside or in- 
side of the joint circumference. There is a sudden painful locking of 
the joint. 

The patient himself is often able to relieve the condition by a little 
manipulation of the joint, combined with lateral pressure. The 
injury is a serious one, functionally, and demands prolonged rest, in 
the hope that union may occur. An elastic silk stocking for the knee 
gives support and ' ''. prevent recurrence of the trouble, but 
violent movements arv. aimost sure to bring a return. If asepsis is 
assured, the joint may be opened and the cartilage sutured to the 
tibia — an operation to be advised by the general practitioner and yet 
scarcely ever necessary to be undertaken by him. 

DISLOCATION OF THE PATELLA. 

The difficulties in correcting the displacement of the patella are 
various, depending not only on the character of the dislocation but 
also on the condition of the ligaments and muscles. 
In general, there is one method of treatment, viz.: 
Extend the leg completely and, holding it in extension, flex the 
thigh to a right angle. By this means, the quadriceps extensor in 
whose tendon of insertion the patella is lodged, is relaxed, permitting 
the bone to be manipulated into place. 

DISLOCATION OF THE ANKLE AND TARSUS. 

The diagnosis and correction of these injuries are more especially 
matters of anatomy. Whoever has clearly in mind the relations of 
the components of the foot, can determine the character of the disar- 
rangement with the minimum difficulty. 



244 



INJURIES TO JOINTS. 



If the diagnosis is wrongly made, correct reposition is lacking, 
and in consequence there persists a degree of deformity and loss of 
function. 

One must begin his task of diagnosing a serious injury to the foot 
by recalling the relation of the malleoli and astragalus, the os calcis 
and the other tarsal bones, to each other. 

Inspect the foot; the heel, the sole, the borders, the malleoli, the 
tendo-achilles — and compare each of these, point for point, with the 
sound side. Remember that the line of the tibial crest, prolonged, 
falls on the second toe. 

A dislocation of the ankle joint assumes 
various forms. The other bones may be 
dislocated from the astragalus, which retains 
its normal relation to the malleoli. There 
may be solely a dislocation of the astragalus, 
which may take almost any position imagin- 
able. Less often one finds displacement of 
the metatarsals and phalanges. 

It is scarcely possible to indicate an exact 
method of reducing such luxations. The 
surgeon's ingenuity must suggest the proper 
variations .of traction combined with pres- 
sure. A type may be foimd in backward 
dislocations oj the ankle (Fig. 184; 

The malleoli are carried forward, the 
heel is elongated, the foot shortened. There is a fold in front of the 
ankle, ridged by the stretched tensor tendons. 

Reduction. — The patient's foot projects over the end of the couch, 
an assistant steadying the flexed knee. Grasp the heel with one 
hand and the middle of the foot with the other (Fig. 185). Make 
traction at first to relax the opposing muscles and then shove the foot 
forward and at the same time flex it. 

After -treatment. — The injured joint, carefully padded, must be fixed 
by a plaster splint. After eight to ten days, passive motion and 
massage must be begun, 




Fig. 184. — Backward disloca- 
tion of ankle. (MouUin.) 



COMPOUND DISLOCATIONS. 245 

COMPOUND DISLOCATIONS. 

These are accidents always to be dreaded, and yet they yield ex- 
cellent results under antiseptic methods. 

Before you is a joint wide open, the articular surfaces bare, perhaps 
protruding, and immediately you think of resection or amputation, 
and yet you will do neither. You will proceed to do a most careful 
disinfection and to secure a complete reposition and immobilization. 
The one chief concern is disinfection. 

The same indications for treatment are present as in compound 
fracture into joints (see page 218 j and depend upon the degree of 
injury to the soft parts and whether the infection is or is not obvious. 




Fig. 185. — Reduction of dislocated ankle. The assistant steadies the 
flexed Tcnee. (Heath.) 

The skin about the wound is f repared as for a surgical operation, 
the wound is thoroughly flushed oat with sterile water, foreign bodies 
are removed, and replacement is effected. The next step will vary, 
depending upon the degree of confidence in having completely steril- 
ized the joint cavity. If the effort has been exacting in that regard, 
tightly suture the deep layers over the joint, close the superficial 
layers with interrupted sutures and apply drainage. 

If the articular structures were impregnated with dirt, despite the 
greatest care in cleansing, one will still fear suppuration and will 
close the wound less firmly and provide for free drainage. Remov- 
ing as many bacteria as possil)le, starving those that remain by re- 



246 INJURIES TO JOINTS. 

moving their food supply — devitalized tissue and blood serum — are 
the principles of treatment; cleansing and draining, the means; 
healing without inflammation or suppuration, the end. 

Dressing and Ajter-care. — Having provided for drainage, cover the 
wound with sterile gauze, envelope the limb in absorbent cotton and 
immobilize the joint with a plaster splint. 

As soon as the soft parts are healed and the danger of infection has 
passed, begin massage of the muscles and slight movement of the 
parts daily. 

"But in spite of careful cleansing, infection may develop. On the 
third day, perhaps, a chill occurs, the fever mounts rapidly and there 
are all the local signs of inflammation and sepsis. Do not temporize, 
but immediately open the wound, douche thoroughly with peroxide 
or iodine water and leave the wound open. Immobilize. If the 
temperature does not fall and the local conditions do not improve in 
a few hours, proceed at once to do an arthrotomy (see page 340). 

The thorough drainage by this means obtained will usually control 
the situation. The drainage is gradually withdrawn and will not be 
necessary after about the tenth day. If, even then, the swelling and 
fever do not subside, there is nothing left to prevent a general in- 
fection but immediate amputation, and even that may be too late. 

The shoulder joint rarely suffers a compound dislocation. Such an 
injury is especially serious for the reason that there are so many com- 
plications; the shoulder muscles are torn, the axillary vessels and the 
nerves of the brachial plexus lacerated. 

It must be treated on the general principles enumerated and the 
result is often surprisingly good. If traumatic aneurism exists, the 
pectoralis muscles must be divided, the space exposed and the vessels 
ligated. 

The hip joint is occasionally the site of a compound dislocation and 
nearly always the shock is fatal. 

Elbow. — This is a comparatively frequent accident and is treated 
on the general principles outlined. If the injuries are severe, a partial 
excision may be required to perfect drainage and insure a better joint. 
Amputation will be indicated only in old age, morbid constitutional 
disability, or extreme local destruction. 



WOUNDS OF THE KNEE JOINT. 247 

The 2i;m/ should be treated conservatively. A loose carpal bone 
may require removal or partial resection. Amputation will be re- 
quired if healing is obviously out of the question. 

Compound dislocations of the knee joint are very rare. If con- 
servatism fails, amputation is the only alternative. 

Ankle and Tarsus. — These dislocations are frequent and require 
much attention. Antiseptic foot baths serve an excellent purpose 
though the primary cleansing must be especially vigorous. The 
tarsal bones may need to be sutured to be retained in place. Especial 
care must be taken not to interfere with the circulation (see page 219, 
compound fractures). 

CONTUSIONS OF THE KNEE JOINT. 

These are so frequent as to call for a special word. The aim is to 
avoid an acute synovitis, which may become suppurative. In milder 
cases, rest in bed with some mild liniment and light massage will 
be sufficient, and the pain and stiffness will rapidly subside. 

In the severer cases, indicated by pain and swelling, more active 
measures must be instituted. 

Wrap the joint in absorbent cotton and apply a plaster bandage for 
two or three days. The uniform pressure will limit the effusion and 
hasten its absorption. After that you may begin hot sponging and 
very gentle passive motion with massage, applied at first only to the 
muscles moving the joint and afterward, as the tenderness subsides, 
to the joint itself. 

PUNCTURE AND STAB WOUNDS OF THE KNEE JOINT. 

The treatment will depend largely on the instrument which in- 
flicted the wound and the appearance of the wound. If the wound 
is clean cut, and the instrument presumably non-septic, content your- 
self with sterilizing the field of the wound, enveloping the knee in an 
antiseptic compress and putting the joint at rest, preferably in a plaster 
splint. You will anxiously watch the temperature. If it does not 
rise within three or four days, one may cease to fear infcctit>n, and such 
swelling as appears is not significant. 

It is quite different when the temperature begins to rise and the local 



248 INJURIES TO JOINTS. 

symptoms gradually increase, or if the wound is seen after some days 
of neglect and the symptoms of infection are fully developed. 

Under these circumstances, there, must be no delay. Immediate 
operation is imperative; it is indicated to do an arthrotomy, disinfect 
and drain (see page 340). 

This treatment, early and properly applied, will save the joint. 
As infection subsides, the drainage is gradually withdrawn. 

There are cases, however, in which unfortunately, even these 
strenuous measures fail. In spite of immediate recognition of the 
urgency, and immediate action, laying open the joint with the utmost 
freedom, followed by repeated irrigations — in spite of the utmost 
endeavor, the symptoms of grave general infection persist and it is 
necessary to amputate. This may save the patient's life — more often 
it will not. 

EXTENSIVE INCISED OR LACERATED WOUNDS OF 
THE KNEE JOINT. 

In these cases, it is never sufficient merely to cleanse the skin and seal 
the wound with antiseptic dressings. The wound must be enlarged, 
thoroughly cleansed, and the joint cavity irrigated with sterile water 
or normal salt solution and wiped dry with sterile gauze. 

After the complete disinfection, the wound in the capsule is sutured 
and, perhaps, also the skin. More frequently, however, one will 
feel safer to leave drainage in the skin wound. The joint is immobil- 
ized, and if everything goes well, the drainage tube is removed after 
forty-eight hours. 

SPRAINS. 

In general, these conditions are to be treated by firm bandaging for 
two or three days, to limit the swelling and hasten the absorption of 
the effusion; and then massage and slight passive motion are begun. 
It is better to give the joint functional rest until at least the greater 
part of the pain has subsided. 

The ankle joint is more frequently sprained than any other, partly 
on account of its construction, and partly on account of its function. 
The weight of the body falls on the insecurely poised foot and the 
ankle gives way under the load. The ankle usually bends outward 



MASSAGE OF A SPRAINED ANKLE. * 249 

and the external lateral ligaments are subjected to great strain. They 
are undoubtedly often lacerated, or the capsular ligament may be 
torn. The pain in the severe cases is immediate" and intense; the 
patient may faint. If the joint is continued in use, the swelling is 
aggravated, but in any event swelling rapidly ensues. 

Morphia may be necessary to relieve the pain. If seen at once, the 
ankle is immobilized in plaster-of-Paris for a few days, or bandaged 
tightly with a flannel or rubber bandage, or strapped with adhesive 
plaster, after which massage and passive motion are employed. The 
patient should walk with crutches at first. The joint will be stronger 
than if it was used before the pain and swelling had subsided, although 
excellent authorities advise walking from the first. 

If adhesive strips are used, in order to avoid circular constriction, 
apply them in this manner: cut the adhesive strips one-half inch 
wide and in two lengths, twelve and eighteen inches. 

(i) Begin with one of the long strips in front of the big toe, carry 
the strip back around the heel, keeping just above the contour of the 
sole, and bring the strip back across the dorsum of the foot to the 
starting point. Overlap this with a similar strip. Both should be 
tightly drawn. 

{2) Begin with one of the shorter pieces above the ankle and carry 
it under the heel to the opposite side. 

The subsequent strips are applied alternately in this fashion, each 
overlapping the one preceding, until the foot is practically covered. 

The whole is then enclosed in an ordinary roller bandage and the 
foot kept quiet. After two or three days, the patient may begin to 
move around a little, but the dressing must be left on till the pain and 
swelling have subsided. It may be reinforced by additional strips 
placed over the loose ones. 

The manner of giving massage is also important. In the case of a 
tender joint, begin by gently stroking the healthy tissues just above 
the joint in the direction of the blood and lymph currents, and grad- 
ually approach the joint. The movements are gradually made more 
vigorous, using the palmar surface of the hand. After a few minutes 
of this work, the joint will usually permit a direct manipulation and 
finally slight passive movement is begun. 



CHAPTER XV. 
INJURY AND REPAIR OF TENDONS. 

There are three kinds of injuries to tendons which it is practical to 
consider as emergencies: dislocated tendons, subcutaneous rupture, 
and divided tendons. 

Dislocation oj Tendons. — Dislocation is not a frequent injury and 
yet it occurs and is to be considered as a possibility in making a diagno- 
sis of disturbances of function after certain joint accidents. 

The tendons most frequently dislocated are those of the peronei 
muscles, especially the brevis. Following a severe wrench of the 
ankle, it is torn out of its sheath behind the external malleolus and 
carried forward onto the malleolus, where it can be felt and moved. 

It is easily replaced but it is with more difficulty retained. The 
ankle must be immobilized and the tendon retained by pressure until 
the ruptured tendon sheath or lateral ligament is healed. It will 
sometimes be necessary to expose the tendon and repair the ruptured 
tissues. 

The long tendon of the biceps may be wrenched from its groove in 
the humerus and the loss of function and prominence of the head of 
the humerus may suggest dislocation of the humerus. As a rule, 
the tendon is easily replaced by a little manipulation, but the useful- 
ness of the arm w^ill be impaired for a long time. 

The other tendons of ankle and wrist occasionally may suffer simi- 
larly but not seriously. 

Subcutaneous Rupture. — Subcutaneous rupture is especially likely 
to occur with the tendon of the quadriceps extensor or triceps cubiti or 
the tendo-achilles. A sudden violent effort is the usual cause. 

The pain, the loss of function, the gap between the ends of the rup- 
tured tendon, and the history of sudden muscular contraction, point to 
the nature of the injury. 

There is only one logical treatment, viz.: by an incision to expose 

250 



RUPTURE OF TENDONS. 



25^ 



the tendon at once and by some of the methods shortly to be described, 
reunite the parts by suture. It is the duty of the doctor to insist on 
nothing less (Fig. i86). 

If this procedure is not followed, it remains only by position, rest 
and massage to favor repair, which, at the best, will be uncertain and 
slow. 




Fig. 1 86. — Repair of ruptured tendon of quadriceps extensor femoris. d, tendon; 
c, basting stitches; h, sutures uniting posterior edges; a, sutures uniting anterior 
edges of ruptured tendon. (Bryant.) 

The position must be such as to relax the muscle, the limb must be 
immobilized, and after the first few days massage must be begun and 
carried out systematically. 

Gage, of Worcester, Mass., treated three cases of rupture of quad- 
riceps extensor in 1904. The history of one of the cases is typical. 
A man, 57 years old, slipped and fell with his left knee doubled under 



252 



INJURY AND REPAIR OF TENDONS. 




Fig. 187. — Incised wound of back of wrist. Divided tendons exposed. (Veau.) 




Fig. 188. — "Expression" of retracted end of divided tendon by forced flexion 
and compression of forearm. (Veau.) 



OPERATION OF RUPTURED TENDON. 



253 



him. He could not lift his leg from the ground. Examination an 
hour later showed a gap 6 cm. wide between the upper border of the 
patella and the retracted edge of the quadriceps tendon. 

Operation. — A transverse incision was made across the front of the 
knee and the ruptured tendon exposed. The rupture was complete 
except for a few^ fibers on the outer edge. The joint was exposed, the 




Fig. 189. — Exposure of tendons by enlarging wound in aponeurosis. 
Suturing tendons. (Veau.) 



clots wiped out. The edges of the tendon were then carefully coapted 
with interrupted catgut sutures. The leg was put up in plaster-of- 
Paris splint for seven weeks. After that it was massaged daily and the 
splint definitely removed at the end of twelve weeks. The leg became 
as strong and flexible as before the accident. 

Divided Tendons. — These are found frequently, especially at the 
wrist, They must he immediately sutured for then it is relatively easv. 



254 



INJURY AND REPAIR OF TENDONS. 



Later they retract or acquire adhesions and it is difficult to, approxi- 
mate the two ends and one must have resource to special manoeuvres. 

Use No. I or No. 2 silk or chromicized catgut. A small curved 
needle or a straight sewing needle will serve. 

Begin by carefully disinfecting the wound and securing complete 
hemostasis. The lower ends of the divided tendons will usually be 
found near the low^er lip of the wound (Fig. 187J. Identify each and 



SI.P 



,c.cJ 



CF2?. 




jir.k 



J^p 



•v/./- 



Fig. 190. — Cross section showing relations of the various tendons at the wrist joint. 
N.R., radial nerve; L.F.P., long flexor of the thumb; A.R.. radial artery; G.P., 
palmaris longis; N.M., median nerve; L.F., flexors of the fingers; A.C., ulnar 
artery; N.C., ulnar nerve; C.P., ext. carp, ulnar; C.P.D., ext. min. dig., C.C.D., ext. 
com. digitorum; L.E.P., ext. long, pollicis; R, extensors carp, rad.; M.P., supinator 
longus, extensor brev. pollicis. 



count them to be sure none have been overlooked. At the same 
time, see if a nerve has been divided. Look for the others of the di- 
vided ends. If they are not in sight, do not reach blindly for them 
with forceps, but attempt to bring them into view by "expression," 
and if this fails, boldly enlarge the wound. 

Expxession. — Direct the assistant to grasp the member above the 
wound with both hands and the pressure may force the tendons into 



SUTURE OF TENDONS. 



255 



view. If the extensor tendons are involved, employ forced flexion 
with the pressure. These muscular groups are 
more or less unified and the divided tendons put on 
the stretch help to drag the divided tendons into 
view (Fig. i88). 

If this method does not succeed, apply a roller 
bandage beginning at the elbow joint in the case of 
the upper extremity; at the knee in the case of the 
leg or foot, and carry it down to within an inch of 
the wound. If this too fails, make a jree incision 
observing this point; do not make the incision directly 
over the tendon for it may later acquire adhesions 
to the scar tissue, interfering with, its free move- 
ment (Fig. 189). Generally with a little patience the 
tendon is found. It is often practical after incising 
the skin to make a diagonal incision of the deep 
fascia or two incisions at a right angle, creating a 
flap which may be dissected up and the tendon group 
well exposed (Fig. 190). 

Suture of the Tendon. — (A) The tendon is round, 
as at the level of the wrist joint. Seize the tendon Fig. 191. — One 

. . . method of suturing 

With a dissectmg forceps, bemg careful not to bruise tendon of medium 

-rv 1 1 1 • 1 size. (Veau.) 

It. rass a suture through the whole thickness one- 
quarter inch from the end (Fig. 191), entering the superficial surface 

and emerging on the deep sur- 
face of the segment and carry- 
ing it then to the other part; 
entering the deep surface and 
emerging on the superficial 
surface. The ends of the di- 
vided tendon are then coapted 
and the suture tied. 

The suture may be passed 
laterally instead of antero- 
posteriorly. If the ends of the 
tendon come together well, a suture may be entered one-half inch 




e.J)«i£vr.a 




Fig. 192. — Method of introducing suture for 
divided tendon. (Marsee.) 



256 



INJURY AND REPAIR OF TENDONS. 




Fig. 193. — Suture of tendons completed. Repair of aponeurosis. The aponeurosis 
should not be divided directly over the tendons else adhesions may occur. (Veau.) 





Fig. 194. ^Suture of a flattened 
tendon, (Veau.) 



Fig. 195. — Suture of a lacer- 
ated tendon. (Veau.) 




ANASTOMOSIS OF TENDONS. 257 

from the divided end and passed obliquely in such a manner that it 
emerges from the cut surface and then is passed into the cut surface 
of the opposite end and emerges symmetrically with the original point 
of entrance. Marsee advises passing a separate suture three times 
through the tendon, tying the corresponding ends (Fig. 192). 

Repair the wound in the deep fascia by a continuous suture, being 
assured once more that no nerve is divided (Fig. 193). . 

(B) The tendon is -flattened. In this case, the ends must overlap. 
Make a latero-lateral anastomosis; pass the suture through the lower 
end from before backward, beginning near one border. 
Next pass the suture through the upper end from before 
backward and again from behind forward. Finally pass 
the suture from behind forward through the lower end. 
When the suture is ready to tie, the lower end overlaps 
the upper (Fig. 194). 

(C) The tendon is shattered or lacerated. In this case 
before suturing tie a firm ligature around either end, which 
will prevent the suture from pulling out (Fig. 195). 

(D) The tendon is voluminous. In this case it is better 
to vary the method a little. Pass the transverse suture as 
in Figure 191. Before tying the suture, the posterior lips 
are drawn together as neatly as possible. When these 
sutures are all tied, finally suture the anterior lips together. 
Over all suture the deep fascia. The transverse suture Fig. 196.— 
must be strong, No. 3 silk for example, though the others elongating a 

, _ tendon. 

may be finer. 

(E) The ends cannot he approximated. This will not happen ex- 
cept in the neglected cases. Two precedures are practical. 

(i) The space may be bridged by sutures, which will favor reunion 
by scar tissue. Begin by ligating both ends (Fig. 195) and then pass 
three to sk sutures as the one is passed in the figure. 

(2) The space may be bridged by splitting the upper tendon in 
the manner indicated in Figure 196. Before the tendon is split, it 
must be ligated near its end. In the case of the tendo-achilles, it may 
be lengthened by making several half cross sections at different levels, 
first one side and then the other. 
17 



258 



INJURY AND REPAIR OF TENDONS. 





Fig. 197. — Suture by double anastomosis 
when the two ends of the divided tendon 
cannot be brought in contact. (Veau.) 



Fig, 198. — The upper end cannot be 
found. ^Suture to adjoining tendon. 
(Veau.) 




Fig. 199. — The long extensor of the thumb divided, the upper end lost. The adjoining 
tendon is split and one segment sutured to long extensor. (Schwartz.) 



DRAINAGE AFTER TENDON-SUTURE. 



259 



(3) The two ends may be sutured to a neighboring tendon (Fig. 197). 

(F) The upper portion oj the divided tendon cannot he found. In 
this case, buttonhole a neighboring tendon, selecting one nearest 
resembling in function the divided one. Into the slit pass the end of 
the divided tendon and fasten with one or two sutures. The divided 
tendon should be slightly on the stretch when the suturing is completed 
(Fig. 198). 

The healthy tendon may be split and the separated portion sutured 
to the divided tendon (Fig. 199). 

Drainage. — Drainage is necessary if the wound was accidental. A 
small drainage tube is left beneath the skin. The fascia has been 
completely closed. Apply a dry antiseptic and absorbent dressing. 




Fig. 200. — Plaster splint applied to 
maintain flexion. 



Immobilize the part in a position, flexion or extension, to relax 
the tendons. If necessary, apply a plaster bandage over the dressing. 
An excellent splint is made by taking a plaster roller, properly soaked, 
and folding it back and forth pressing the folds carefully together 
until a five to eight ply splint of proper width and length is made. 
This is slightly padded, bandaged in place and held at the necessary 
degree of flexion till set (Fig. 200). 



CHAPTER XVI. 



INJURY AND REPAIR OF NERVES. 
THE REPAIR OF DIVIDED NERVES. 



It is imperative to suture a divided nerve as soon as the condition 
is recognized. If the repair is made at once it is more easily done than 
the suture of tendons, for the ends are not so widely separated; but, 
on the other hand, it is more delicate work, for the trunks are smaller. 
Do not handle these tissues roughly and above all do not cleanse the 
wound with strong antiseptics such as bichloride and carbolic acid. 

Remember that the upper pa.rt of the 
nerve retains its sensitiveness and in it are 
the essentials of repair. The lower seg- 
ment degenerates if repair is neglected. 

It is usually necessary to freshen the 
ends, but one must be very sparing of the 
tissues, removing less than a millimeter 
from each extremity, using fine sharp 
scissors. It is better to make the section 
oblique (Fig. 201). 

Pass a silk (No. o) suture or a small 
catgut with a round needle through the 
whole thickness, as in the case of a round 
tendon (Fig. 202), draw the ends together 
and complete the repair by suturing the 
lips, passing the suture through the nerve sheath only (Fig. 203). 
Adjust the ends exactly and always w^here possible make the suture 
an end to end one. 

Repair the various layers of fascia with great care, so that the nerve 
suture may be isolated and removed from the sources of infection. 
Employ drainage in suturing the skin. 

For the rest, the treatment is the same as for any other wound. 

260 



Fig. 201.— Ob- 
lique section of 
the nerve ends. 



I 

Fig. 2C2. — 
Through and 
through suture 
of nerve. 

(Veau.) 



CONTUSION AND COMPRESSION OF NERVES. 



261 



Secondary Suture. — It may be found necessary to suture a nerve 
some time after the injury and this operation will 
present difficulties. The ends may be separated or 
they may be imbedded in scar tissue. 

A knob often forms on the proximal stump. In 
such a case, freshen the ends and pass the suture in 
the manner pictured (Fig. 204). 

If the two ends are attached by a fibrous cord, 
split the scar tissue longitudinally (Fig. 205), and 
transform the longitudinal fissure into a transverse 
one and suture (Fig. 206). If the ends can not be 
approximated or bridged they may be sutured at 
different levels to a neighboring nerve in the manner 
described under tendons 

Warn the patient that it may be a long time before 
function is even partially restored. In the mean- 
time, muscular atrophy must be prevented by per- 
sistent use of electricity and massage. 




CONTUSION AND COMPRESSION OF 
NERVES. 



Fig. 203. — Suture 
of nerve through the 
sheath. (Veau.) 




Fig. 



—Secondary suture. Method 
coaptation. (Veau.) 



normal 



idition as 



These injuries to nerves are by no 
means infrequent, following blows, gun- 
shot wounds, machinery accidents, frac- 
tures and dislocations. 

The symptoms vary from slight ting- 
ling to complete loss of function. The 
loss of function is often a later develop- 
ment, due to a neuritis following the 
contusion, and is accompanied by 
neuralgia, muscular palsy and trophic 
alterations corresponding to the distri- 
bution of the nerve. 

Treatment. — The immediate indica- 
tions are to restore the parts to their 
much as possible, and to relieve the pain by 



262 



INJURY AND REPAIR OF NERVES. 



hypodermic injections of morphia or by phenacetine and codeine. The 
nerve must be put at rest by immobilizing the limb. Later, alteratives, 
electricity, and massage are useful. 



- INJURIES TO INDIVIDUAL NERVES. 

Facial Nerve. — The facial isi' more frequently injured than any 
other cranial nerve: in fracture of the base of the skull; in the mastoid 
operation as it passes through the temporal bone; by shots and blows 

at its exit from the styloid 
foramen. Depending upon 
the distance of the lesion from 
the central origin of the nerve, 
there occur paralysis of the 
muscles of expression, dis- 
turbance of salivary secretion 
and the sense of taste, and 
paralysis of the palatal mus- 
cles. Injury to the facial 
nerve is often accompanied 
by injury to the abducens 
and auditory nerves. 

To Expose the Facial 
Nerv.e. — The incision begins 
behind the external auditory 
meatus and extends down- 
ward and forward to the 
angle of the lower jaw. 
Divide the integument, 
superficial fascia and the first layer of the deep fascia. This exposes 
the parotid gland, the sterno-cleido-mastoid and the mastoid process. 
The posterior auricular nerves and the vessels are to be avoided. 
Carefully dissect and draw forward the part of the gland exposed and 
the posterior belly of the digastric appears, just above which the 
nerve lies upon the styloid process. 

Optic Nerve. — The optic nerves are injured most frequently in con- 




FiG. 205. Fig. 206. 

The two ends of the nerve are connected by 
fibrous cord which is spHt longitudinally and su 
tured as indicated. (Veau.) 



EXAMINATION FOR BRAIN TRAUMA. 263 

nection with fracture of the base of the skull involving the anterior 
fossa, and especially when the fissure involves the optic foramen, 
for there the nerve is firmly attached to the bone. 

As a consequence of such injuries, there may be compression, lacera- 
tion, or extravasation into the nerve sheath. As a result of these in- 
juries, there are disturbances of vision of various degrees. In obscure 
trauma oj the brain, the ophthalmoscopic examination of the fundus of 
the retina should never be neglected as a means of diagnosis. 

Motor Oculi Nerve. — The motor oculi nerve may be injured by 
wounds penetrating the orbit and by fractures of the base. Its func- 
tion may be disturbed by pressure following the rupture of the middle 
meningeal artery and often the only indication of this disturbance is a 
dilated pupil and drooping of the eyelid. 

Patheticus and Abducens. — These nerves are often injured along with 
the third. 

Fifth Nerve. — The fifth nerve is rarely injured alone but injury of 
single branches may occur. 

"The usual consequence of anesthesia of the trigeminals following 
cranial injury is so-called keratitis neuroparalytica." 

Auditory Nerve. — The auditory nerve is rarely injured without 
other serious lesions, and since traumatic disturbances of hearing may 
be due to injury to the labyrinth or tympanum also, a diagnosis of in- 
jury to the nerve trunk must be uncertain. 

The pneumogastric may be divided or contused by bullet or stab 
wounds in the neck. The injury is not necessarily fatal, but may be 
followed by difiiculty in respiration and deglutition or by pneumonia. 
When the symptoms point to injury an effort should be made to repair 
it. It is reached by the same operation as that for ligation of the 
common carotid. 

The phrenic when divided gives rise to disturbances of the functions 
of the diaphragm, cough, difficult respiration. 

The recurrent laryngeal when divided gives rise to hoarseness and 
aphonia. If injured an attempt should be made at repair. Laryngeal 
spasm may require a tracheotomy. 

Median Nerve. — The median nerve is likely to be divided by stab 
or gunshot wounds and may be exposed in any part of its course. 



264 



INJURY AND REPAIR OF NERVES. 



Injury to the median nerve results in impaired flexion of the hand 
and fingers and movements of the thumb. 

To Expose the Median Nerve. — (A) In the middle third of the arm 
(Fig. 207): Place the patient on the back with arms abducted to a right 
angle, the operator standing to the inner side of the arm. 

With the two hands define the biceps muscle. Along the inner 
border of the muscle, following the known line of the nerve (from the 
middle of the axilla to the middle of the bend of the elbow) make an 
incision two or three inches long, dividing the skin and connective 
tissue. Divide the deep fascia over the biceps and open the sheath 




Fig. 207. — Exposure of the median nerve in the middle third of the arm. B. Biceps. 
M. N. Median nerve. B. A. Brachial artery. (Schwartz.) 



of the muscle. Isolate the border of the muscle and w^ith the retractor 
draw it gently aside. Do not use force or the nerve also will be dis- 
placed or the musculo-cutaneous may be exposed instead of the median. 
Now incise the deep layer of the muscle sheath exactly in the line 
that was occupied by the border of the muscle and the nerve is exposed 
lying a little to the inside of the vessels. 

(B) At bend of elbow (see brachial artery). 

(C) In the upper third of the forearm (Fig. 208) : The incision begins 
a little below the bend of the elbow, is two or three inches in length 
and follows the line of the nerve, which lies in the middle line from 



INJURY TO THE ULNAR NERVE. 265 

the elbow to the wrist. Divide the skin and ligate the two superficial 
veins. Under the deep fascia define the external border of the pro- 
nater radii teres and over this border incise the aponeurosis and retract 
the muscle. 

The nerve is immediately exposed, together with the ulnar artery, 
which crosses beneath it, running obliquely toward the inner border 
of the forearm. 

(D) At the wrist (Fig. 209) . Make an incision two inches in length 
in the middle line, the middle of the incision corresponding to the crease 




Fig. 208. — Exposure of the median nerve just below the elbow. The pronator radii 
(p.R.T.) teres drawn inward exposing the median nerve (m. n.), the ulnar artery 
( u. art.) being at outer side. (Schwartz.) 

of the wrist. Divide first the skin and the fascia and then, very 
carefully, the anterior annular ligament, guarding the synovial sheath 
of the flexor tendons. Retract the lips of the wound and the nerve is 
exposed, easily distinguishable from the adjacent tendons by its fi- 
brillated appearance. 

The Ulnar Nerve (Fig. 210). — The ulnar nerve may be divided any- 
where along its course, but is more likely to be contused in the ulnar 
groove. There also it may be dislocated by forcible flexion of the 
forearm. The loss of function of this nerve results in inability to extend 
the distal phalanges, to adduct the fingers and to flex the little finger. 



266 



INJURY AND REPAIR OF NERVES. 



Eventually the ^^ claw hand'' appears as a result of atrophy of the 
muscles. 

To Expose the Ulnar Nerve. — (A) In the arm: Make an incision 
two or three inches in length along the line of the nerve, which ex- 
tends from the middle of the axilla to the internal condyle. Divide 
the skin and superficial and deep fascia. The brachial artery is 
about a finger's breadth to the outside of the line of incision. Draw 



Med.N; 




Fig. 209.- — Exposure of the median nerve at 
the wrist. (Schwartz.) 



Fig. 2 to. — Exposure of the ulnar nerve in 
the upper third of the arm. M. N. Median 
nerve. B. A, Brachial artery. U. N. Ulnar 
nerve, Tr. Triceps muscle. (Schwartz.) 



the basilic vein to one side. Carefully divide the subjacent tissue 
beneath which is the ulnar and median nerves and the brachial artery; 
the ulnar nerve is to the inside and in contact with the long head of 
the triceps. 

(B) At the elbow (Fig. 2[i): Place the patient on the back; 
abduct the arm; flex the forearm at a right angle; stand to the inner 
side of the arm and locate the inner condyle, the olecranon and the in- 
tervening gutter. Along the line of the gutter incise the skin and the 



INJURY TO MUSCULO-SPIRAL NERVE. 



267 



fascias for two or three inches and the nerve will be exposed, accom- 
panied by the posterior ulnar recurrent artery. 

(C) In the lower third of the forearm (Fig. 2J"2): Following the 
line of the nerve, from the internal condyle to the radial side of the 
pisiform, make an incision two inches long to the outside of the flexor 
carpi ulnaris, dividing the skin and superficial fascia. Retract inward 
the tendon of this flexor. Carefully incise the deep fascia and the nerve 
is exposed lying to the ulnar side of the ulnar artery. 




I.e. 

~~^^^ / U.N. 

-^^ -^ Olec. 

Trie. 



Fig. 211. — Exposure of the ulnar nerve at elbow. I. C. Internal condyle. 
E. C. U. Extensor carpi ulnaris. U. N. Ulnar nerve. Olec. Olecranon process. 
Trie. Triceps. (Schwartz.) 



Musculo-spiral. — The musculo-spiral, more than any other nerve 
of the arm, is subject to injury from stab, contused or gunshot 
wounds or to fracture of the humerus. Very characteristic, too, 
are the symptoms resulting from its loss of function. The wrist 
and fingers cannot be extended and assume the attitude well known 
as the "drop wTist." In every fracture of the humerus, the stability 
of this nerve should be tested. The nerve may be explored in any 
part of its course but is most easily reached at the outer side of the 
arm just above the elbow. 



268 INJURY AND REPAIR OF NERVES. 

To expose the Musculo-spiral. — In the loiver third of the arm (Fig. 
213): The arm is abducted, the forearm extended and the hand 
supinated. Stand to the outside of the limb. In the line of the 
nerve, a line drawn along the middle of the external surface, begin- 
ning half way between the shoulder and elbow and extending to a 
point one-half inch from the center of the bend of the elbow, make an 
incision two or three inches in length through the skin and superficial 
fascia. Retract the cephalic vein. Divide the deep fascia along the 



Fig. 212. — Exposure of the vilnar nerve at the wrist. U. A. Ulnar artery. 
U. N. Ulnar nerve. (Schwartz.) 

border of the supinator longus and expose the muscle fully. Retract 
it to the outside. At the bottom of the wound is the nerve lying upon 
the brachialis anticus. 

Circumflex. — In addition to such injuries as may be due to stab or 
gunshot wounds, the circumflex is liable to be lacerated in violent 
wrenching or in dislocation of the shoulder joint. 

The loss of power to abduct the arm through paralysis of the deltoid 
is the immediate result. The nerve may be exposed as it winds around 
the humerus just below its head. 

Opexation. — The course of the nerve is in a line drawn from the inner 
end of the scapular spine, to the point of insertion of the deltoid. 

Place the patient on the sound side, exposing the shoulder well by 
rotating the arm inward a little and placing it in front of the trunk. 



INJURY TO THE ANTERIOR CRURAL NERVE. 269 

Along the line indicated make an incision three or four inches long, 
corresponding at its outer end to the acromion process but an inch or 
two from it. This incision divides the skin and superficial and deep 
fascia and exposes the posterior border of the deltoid. Bring into 
view and draw upward this border of the deltoid. 

Next locate the quadrilateral space, bounded above by the teres 
minor, below by the teres major, posteriorly by the long head of the 




Sup. Long. 
Mus. Sp. 
Br. Ant. 



Fig. 213. — Exposure of the musculo-spiral in its lower third. The supinator longus 
is exposed and the nerve found to its inner side lying upon the brachialis anticus. 
(Schwartz.) 



triceps and anteriorly by the shaft of the humerus. By locating the 
tendons of these muscles define this space in which lie the nerve and the 
posterior circumflex artery (Fig. 214). 

The Musculo-ciUaneous is exposed in the same manner as the 
median in the upper third of the arm (Fig. 215). 

Anterior Crural. — The division of the anterior crural nerve means, 
among other things, loss of extension of the leg. 

To outline it locate the spine of the pubes and the anterior superior 
iliac spine, which points are connected by Poupart's ligament; under 



270 



INJURY AND REPAIR OF- NERVES. 



this ligament a finger's breadth outside, of its middle point the nerve 
passes (Fig. 216). 

To Expose the Anterior Crural. — Make an incision from this point 
downward in the axis of the thigh, about three inches in length, divid- 
ing the skin. 




Fig. 214. — Exposure of the circumflex nerve. D. Deltoid. T. M. Teres minor. 
Tr. Triceps. T. Maj. Teres major. C. A. Circumflex artery. C.N. Circumflex 
nerve. (Schwartz.) 



At the upper end of the wound expose the lowxr border of Poupart's 
ligament. Immediately below this line, open up the sheath of the psoas 
magnus, pass a grooved director under the sheath, and divide it to the 
same extent as the skin incision. Separating the lips of the sheath 
wound, the nerve is seen lying on the fibers of the muscle and is to be 
distinguished by its whiteness and its subdivisions. 



ANTERIOR CRURAL NERVE. 



271 




Fig. 215. — Exposure of the inusculo-cuta.neous nerve in the middle third of arm. 
The biceps (B) drawn outward exposes the nerve (M. Cut. N.) lying to the outside 
of the median nerve (Med. N.) and the brachial artery, Br. Art. (Schwartz.) 




Fig. 216. — Anterior crura,! ^nd external cutaneous nerves. (Labcy.) 



272 



INJURY AND REPAIR OF NERVES. 



The Obturator. — If the obturator is divided, there follows loss of ab- 
duction of the thigh. 

To Expose the Obturator. — Abduct the thigh until the border of the 
ductor longus can be clearly defined, and along this line make an in- 
cision four or five inches long, beginning an inch below the fold of the 
groin, a little to the outside of the scrotal base. Divide the skin and 
superficial fascia, retracting to the outer side the internal saphenous 




Fig. 217. 



-Exposure of the obturator nerve; separating the adductor longus from 
the pectineus. (Labey.) 



vein but ligating it across branches (Fig. 217;. Divide the deep fascia 
in the same line. 

Separate the abductor longus from the pectineus by blunt dissection. 
A fairly well-defined gutter indicates the line of separation. Retract 
the two muscles and at the bottom of the upper part of the wound you 
will see the obturator nerve, consisting of a couple of flattened cords. 
Now extend the thigh to relax the abductors and separate more widely 
the two muscles mentioned and the nerve may be completely exposed, 



EXPOSURE OF THE SCIATIC NERVE. 



273 



one branch lying upon the abductor brevis and the other passing under 
it (Fig. 218). 

Ilio-ingiiinal and Genito -crural. — These nerves are frequently 
wounded in hernia operations, and may give rise to an obstinate neu- 
ralgia of the testicle requiring removal of this organ. In such a case 
an effort should be made first to repair the nerve or resect it. 

The Sciatic Nerve. — The sciatic nerve may be injured in many ways 
and from the functional point of view, these injuries are always serious. 




Fig. 2 1 8. — Obturator exposed. (Labey.) 



It may mean loss of extension of the thigh and complete paralysis of 
the leg. 

It may be exposed at any part of its course down the back of the 
thigh. 

Exposure in the Middle oj the Thigh. — Place the patient face down- 
ward or on the sound side. Along the line of the nerve (a straight line 
extending from a point midway between the ischial tuberosity and 
the great trochanter to the middle of the popliteal space), make an in- 
cision three or four inches long, dividing the tissues down to the deep 



74 



INJURY AND REPAIR OF NERVES. 



fascia. Determine the interspace between the biceps and the internal 
hamstring, and over it divide the deep fascia and separate by blunt 
dissection the muscles of the space. 

Flex the leg so as to relax them. They are then to be retracted 
widely and in the fatty tissues of the interval the nerve is usually easily 
found. 

The External Popliteal, or Peroneal. — This nerve, like others, is 
liable to injury in fractures and wounds. When it is divided, "foot 
drop" occurs. The patient cannot walk without stubbing the great 
toe and to prevent this, the whole leg is. raised (steppage gait). This 

nerve bears an important relation 
to the knee joint and to the tendon 
of the biceps. 

To expose the peroneal behind 
the head of the fibula place the 
patient face downward or on the 
sound side. The line of the nerve 
corresponds to the tendon of the 
biceps, which may be palpated 
along the external border of the 
popliteal space, or the course of 
the nerve may be indicated by a 
line draw^n from the tuberosity of 
the ischium to the head of the 
fibula. In this line, beginning at the neck of the fibula, make an in- 
cision upward three inches long, dividing the structures down to the 
deep fascia. Carefully divide the deep fascia over the tendon of the 
biceps and at once there comes into view the external popliteal, lying 
to the inner side of the tendon resting upon the external condyle of 
the femur above, and lower down winding about the neck of the fibula 
and disappearing in the peroneus longus. 

To Expose the Musculo-cutaneous. — Place the patient upon his back 
the knee flexed and rotated inw^ard and retained by a cushion placed 
under the thigh, in this manner exposing the external aspect of the leg. 
The line of the nerve is drawn from the anterior border of the pero- 
neal head to the anterior border of the external malleolus. Along this 




Fig 



219. — Musculo-cutaneous nerve lyin^ 
upon the peroneus brevis. (Labey.) 



EXPOSURE OF THE ANTERIOR TIBIAL NERVE. 



275 



line in the middle of the leg, make an incision three or foui inches in 
length dividing the structures to the deep fascia. 

Incise the aponeurosis of the peronei muscles, isolate the anterior 
border of the peroneus longus and draw it backward. The muscle 
may be previously relaxed by rotating the foot 
outward. The nerve will be seen resting upon 
the peroneus brevis (Fig. 219). 

The Anterior Tibial Nerve. — The anterior 
tibial nerve is the continuation of the external 
popliteal nerve. The movements of flexion of 
the foot and extension of the toes depend upon 
this nerve. 

To Expose the Anterior Tibial Nerve. — 
(A) In the upper third: Put the patient in the 
same position as for the musculo-cutaneous. 

The line of the nerve is drawn from the front 
of the peroneal head to the middle of the ankle 
joint (Fig. 220). 

In the line of the nerve make an incision 
beginning three fingers' breadth below the 
articular line of the knee. Divide to the deep 
fascia; next divide that and then patiently 
search for the intermuscular septum separat- 
ing the wide tibialis anticus from the narrow 
common extensor. It will aid greatly in the 
search to seize with a forceps each of the lips 
of the wound of the sheath and retract. This 
will help to develop the line of cleavage. 

Remember that the tibialis anticus slightly 
overlaps the common extensor, so that the 
intermuscular space slopes inward and back- 
ward. Retracting the muscles, the nerve will appear as a small 
rounded white cord lying in front of the vessels. 

(B) In the lower third (see anterior tibial artery). 

Posterior Tibial Nerve. — The posterior tibial nerve supplies the 
movements of the extension of the foot and flexion of the toes and may 




Fig. 220. — Lines repre- 
senting the course (c) of 
the musculo-cutaneous; 
(a b) Anterior tibial nerves. 
(Labey.) 



276 



INJURY AND REPAIR OF NERVES. 



be wounded in any part of its course, although in the region of the calf 
it is deeply situated. Behind the internal malleolus it is superficial 
and easily exposed. 

(A) To Expose Upper Third. — To expose the posterior tibial in the 
region of the calf is difficult (Fig. 221). 

Position. — Place the patient on his back with the thigh in abduction 
and external rotation, the knee flexed, and the foot lying upon its ex- 
ternal border and held in this position by an assistant. Standing to the 
outside of the limb the operator with this arrangement can see quite 
well the internal surface of the leg. 




Fig. 221. — Exposure of the post, tibial nerve. Gastrocnemius retracted; 
soleus exposed. (Labey.) 



Locate first the sharp internal border of the tibia and a finger's 
breadth behind it make an incision four inches long, beginning at the 
level of the tuberosity. Divide the tissues down to the deep fascia, 
avoiding the internal saphenous vein, which lies close to the tibial 
border. 

Slightly retract the posterior lip, which will include the gastrocne- 
mius, and in this manner the soleus is exposed. Division of the soleus 
is the next step which must be carefully carried out. Divide it longit- 
udinally but further away from the tibia than the original incision 



EXPOSURE OF THE ANTERIOR NERVE. 



277 



Cutting in this manner through the libers of the soleus, the yellow 
aponeurosis covering the nerve and vessels is exposed (Fig. 222). 
Tt is important to. expose this landmark well. Make an opening in it 




Fig. 222. — Fibers of the soleus divided and retracted, exposing deeply 
situated the posterior tibial nerve and artery. (Labey.) 



an inch and a half from the internal border of the tibia, and beneath 
the opening is the nerve, lying to the outer side of the artery. 
(B) Behind the ankle (see ligation of posterior tibial artery). 



CHAPTER XVII. 
ABSCESS. 

An abscess is a circumscribed collection of the liquefied products of 
infective inflammation. 

There are two kinds of abscesses, differing in their etiology, clinical 
history, prognosis and treatment. All these differences arise primarily 
in the nature of the infective agent. The acute abscess is due most 
generally to the activity of certain of the cocci. The chronic (or cold) 
abscess is nearly always due to the bacillus tuberculosis. The chronic 
abscess may become infected secondarily with the germs of acute in- 
flammation, in which instance it takes on the character of the acute 
abscess. 

The content of the acute abscess is pus; that of the chronic abscess, 
though resembling pus, may be merely the liquefied caseated matter 
of the tubercle without any pus cells whatever. An acute abscess pre- 
sents all the cardinal symptoms of inflammation: constitutional dis- 
turbance, pain, heat, redness, swelling, all in greater or less degree, 
depending on the locality. A chronic abscess may present none of 
these symptoms except sw^elling, and where swelling is not perceptible 
the abscess is frequently unsuspected. An acute abscess is of very 
rapid development — the chronic of quite slow growth, as a rule. An 
acute abscess demands immediate evacuation by free incision and 
drainage. The chronic abscess very often permits only of aseptic 
puncture, followed by the injection of detergent remedies, and aseptic 
occlusion. 

Each occurs by choice in certain locations. The incision, the 
special dangers and details of treatment depend on the anatomy of 
the parts, so that the more common abscesses require individual 
consideration, and in that connection the general principles that under- 
lie the subject may be elaborated. 

The prevention of pus formation should be attempted in all acute 

278 



TREATMENT OF ACUTE ABSCESS. 279. 

infectious inflammations by means of the timely application, in favor- 
able localities, of hot antiseptic poultices or prolonged immersion in 
hot antiseptic solutions. Even though the treatment fails to pre- 
vent suppuration, it will at least limit it. Such an antiseptic poultice 
may be made by applying absorbent cotton soaked in hot boric acid 
solution and covering it with oiled silk or gutta percha. In this manner 
heat and moisture are retained. 

The old flaxseed meal poultice is more often than not the breeder 
of germs and therefore distinctly non-surgical — a domestic make- 
shift. Some of the "antiphlogistic" glycerinated and sterile clay 
pastes often render an excellent service. 

Treatment, — The evacuation of an abscess is by many regarded as 
a small procedure in minor surgery. It may be nothing more, and yet, 
as Lejars says, in certain cases it is a formidable task straining the re- 
sources of the most practised. It is an idea too long prevalent that 
there is a minor and major surgery. There is only one kind of good 
surgery w^hether the case is of great or little importance. It is that 
which recognizes the indications and meets them promptly, giving the 
patient relief with the least possible delay. 

Abscesses have too much been regarded as simple conditions which 
the merest tyro might treat. We all know of patients who have 
died of these operations; of others wdio have been disabled by the failure 
to perform them, or by their being tardily or improperly done. And 
how often tardily done ! 

But what excuse can one make for delay after pus has definitely 
formed, for any attempt to bring about its absorption is futile. Delay 
merely means that the collection augments, destroys more tissues, ac- 
quires diverticula without end, which may need to be opened up time 
and time again, or may require months to heal and eventually give 
rise to irremediable contractions and adhesions. 

It is one of the most important and least varying rules of surgical 
practice that every acute abscess, superficial or deep, must as early 
as possible be incised, emptied and drained. 

Another point: do not wait for fluctuation, which is so commonly 
the practice. If the suppuration occurs in the deeper structures, fluc- 
tuation may be delayed. But there are ample indications otherwise; 



28o ABSCESS. 

the rapid increase of swelling, the radiating pains, fever and subcutane- 
ous edema give sufficient evidence that pus is present. 

In certain regions the thick and brawny skin and fascia are as signif- 
icant as fluctuation itself. On the scalp, for instance, this brawny 
edema is a definite symptom of suppuration. In the belly walls, as 
Lejars remarks, the consistency of a deep abscess reminds one of sar- 
coma. 

The edema is superficial; the suppuration, deep. The two processes 
go together and when the first is present, one may unhesitatingly diag- 
nosticate the second. 

To repeat, when the skin pits on pressure and is only slightly reddened 
even, the diagnosis is no longer doubtful and one may — one should — 
operate at once. 

The length of the incision is of the greatest importance. Nothing is 
more unsatisfactory than the mere stab, or puncture, of an acute abscess. 
The incision, cutting through the middle, parallel with the most im- 
portant structures, should open up the whole length of the cavity. 
In this manner no pockets are left behind, and, besides, a long, smooth 
incision will in the end leave the least scar. A counterincision may 
be necessary. 

Once the abscess is opened and the pus has ceased to flow, wipe 
out the cavity with sterile gauze and irrigate with sterile water or some 
antiseptic. If diverticula are found, they too must be freely opened up 
and irrigated. 

Insert a drain. If the abscess was small and the incision made 
early, it is proper to dispense with the drain; but if the suppuration is 
extensive, the best means of preventing large scar formation is to 
employ drainage. 

Observe then, says Lejars that the whole therapy of abscesses is 
contained in these two words, "empty" and "drain." 

You do nothing more — there is nothing more to be done — and it is 
sufficient. To attempt to make an abscess cavity aseptic is wasted 
effort. An abscess contains infection of limited virulence and when 
once it is emptied, the living tissues will do the rest, provided they are 
not embarrassed by new germs introduced by the operation. 

With this notion in view, then, it must be an absolute rule of practice 



TREATMENT OF CHRONIC ABSCESS. 281 

to operate for abscess with clean hands and clean instruments in a 
carefully disinfected field. We may put away for all time the old 
dictum, "If pus is present, antisepsis is useless." 

Disinfect the hands, or what is better the gloves; boil the instruments; 
cleanse the affected area with soap and alcohol and bichloride; then, 
and then only, are you ready to incise the swelling. Wipe out with 
sterile gauze; use sterile tubes. Do not pack with gauze; there is 
nothing more illogical than tamponade of an abscess cavity. Cover 
the wound with sterile gauze and absorbent cotton; and bandage firmly 
so that nothing may enter the wound; so that the dressings will not 
slip or rub. 

The dressings are to be changed daily at first and the tubes every 
second or third day, and are to be shortened as the cavity fills up with 
granulations; are to be dispensed with when pus has ceased to form. 

Treatment of Cold Abscess. — The treatment of a cold abscess 
differs from that of an acute abscess in that incision is not the method 
of choice. 

There is always great danger of infection when the abscess cavity 
is opened up and for that reason incision must be done with circum- 
spection — with an absolute asepsis. There is not the urgency present 
in the acute case. 

Puncture is the method of choice. Employ the strictest antisepsis. 
Wash with soap and water, but not too vigorously lest the abscess 
wall be ruptured; complete the disinfection with alcohol and ether. 
Employ only such instruments as are carefully sterilized. Use a trocar 
of sufficient size that the grumous fluid will not occlude it. Do not punc- 
ture the summit of the tumor if the skin is quite thin, but select a point 
where the tissues are sufficiently resistant to close when the trocar is 
withdrawn. At the end of the evacuation the fluid may need to be as- 
pirated. It may be discolored by some blood from the puncture. 

Injection with some stimulating and antiseptic fluid should follow. 
Ethereal solution of iodoform has the advantage of distending the cavity 
by gas formation and reaching all the diverticula; but it has the dis- 
advantage that it is toxic. Inject 5 to 10 c.c. of a ro per cent solution; 
leave the trocar in place, closing its orifice with the finger. When the 
cavity becomes distended, remove the finger and the ether spurts out. 



252 ABSCESS. 

Let all the gas escape. If one does not observe this rule there may be a 
slough. 

A solution of iodoform in glycerine may be employed; inject 3 to 10 
grammes of a to per cent solution, letting the surplus escape. Cam- 
phorated naphthol may be used in the same way. After the injection 
is completed seal the puncture with collodion. Several injections may 
be necessary for a cure. Constitutional treatment is of the greatest 
importance. . 

ABSCESSES OF THE SCALP. 

These are found in three locations: 

1. Superficial — that is, above the aponeurosis of the occipito-fronta- 
lis. ■ 

2. Subaponeurotic — that is, between aponeurosis and the perios- 
teum. 

3. Subperiosteal — between the periosteum and the bone. 

T. Superficial abscess, due to staphylococci, is quite localized, 
and yet very painful on account of the resistance of the firm tissue. 
The lymph nodes behind the ear and in the back of the neck are 
enlarged and tender. The chief danger is in extension to the deeper 
layers; or the emissary veins may carry infection to the sinuses and 
produce thrombosis or pyemia. Evacuate immediately by free inci- 
sion, first shaving the scalp in the immediate vicinity of the abscess. 

Remembering the manner in which the occipital and temporal 
arteries converge toward the apex, the incision may be managed in such 
a way as to run parallel to the small vessels distributed to the area. 

The cavity must be kept open by a strip of rubber tissue or a small 
drainage tube. A dressing of gauze, absorbent cotton and bandage 
complete the treatment. Change the dressing every day at first. 

2. Subaponeurotic abscess is likely to follow wound infection. 
The streptococci follow the areolar tissues that separate the aponeurosis 
from the periosteum, and the spread of pus is limited only by the attach- 
ments of the aponeurosis. Septicemia, meningitis and thrombosis are 
the actual dangers, and on these accounts immediate operation is de- 
manded. 



FURUNCLE OF THE FACE. 283 

Make a free incision under antiseptic precautions, that is, after 
shaving and cleansing the part involved. 

Do not attempt irrigations, above all, in these cases, for the fluid 
percolating through the loose areolar tissues spreads the infection. 
Good drainage alone will suflice. The dressings must be changed 
frequently at first and must be firm enough to prevent movement of 
the occipito-frontalis muscle. 

If the abscess develops under the temporal fascia, it will not point 
toward the surface, owing to the extreme density of this fascia, but to- 
ward the mouth or neck through the ptergo-maxillary fossa. Even 
though there be no fluctuation (usually indeed, none can be detected), 
the diagnosis can, nevertheless, be certainly made from the presence of 
the edema, redness and pain. Make a vertical incision an inch or so in 
front of the ear and with the center about the level of the eyebrow. 
It may be necessary to go through the substance of the muscle to the 
bone. A few small arteries will be divided and will require ligation. 
It may be necessary at the first dressing to pack the cavity with gauze 
to control slight but persistent bleeding. Drainage by means of tubes 
may be employed subsequently. 

3. Subperiosteal abscesses differ from the others in that they 
are likely to be the result of bone inflammation, tubercular or syphilitic. 
The abscesses are limited to the area of one bone as the periosteum 
along the line of the sutures is continuous with the dura mater. This 
furnishes an easy means of entrance into the cranial cavity for the 
infection and in that manner meningitis may result. For this reason, 
these abscesses, of whatever origin, should be evacuated at once and 
appropriate constitutional treatment instituted. 

ABSCESS AND FURUNCLE OF THE FACE. 

The danger in these conditions is that phlebitis beginning in the 
facial vein may spread to the cavernous sinus, so free is the communi- 
cation by numerous branches between these venous channels. Espec- 
ially to be feared are these furuncles beginning on the upper lip or 
median parts of the face. They may be fatal in a few days. Nearly 
always the staphylococcus pyogenes is the active causative agent and 



284 ABSCESS. 

one need not usually be at a loss to trace the mode of entrance of the 
infection. 

Early incision is imperative in all such acute septic processes. 
The best form of local anesthesia in these conditions is by freezing with 
ethyl chloride spray. Hypodermic injections are best avoided here. 
The incision must be deep to be effective, and in making it, two factors 
are to be borne in mind, the resulting scar and injury to the branches 
of the facial nerve. In severe cases even these points must be dis- 
regarded. Even more certain than free incision is central puncture 
with a fine thermo-cautery. If it is a carbuncle of the diffuse type, 
accompanied by edema of the face and inflammation of the veins, 
crucial incision with curettement must be undertaken. The dressing 
of gauze may be held in place by adhesive strips. 

ABSCESS OF THE NASAL SEPTUM. 

Following a blow upon the nose, bleeding ensues and, two or three 
days later, obstruction. Looking into the child's nasal fossae, they are 
seen to be filled with a bright red, tender, fluctuating swelling, over the 
cartilaginous portion of the septum. The whole nose becomes hot, 
swollen and painful. 

The treatment is evacuation by a free incision of the mucous mem- 
brane over the septum at the point of greatest fluctuation. 

To operate, apply a four per cent solution of cocaine to the mucous 
membrane, and after waiting a minute or two, make an incision along 
the septal wall from above downward and forward with a slender, 
sharp bistoury. Douche the nasal fossa frequently with a mild, alka- 
line antiseptic. Recovery usually follows within a week, although in 
the neglected cases, necrosis of the cartilage may occur. 

ABSCESS OF THE EYELIDS. 

The loose connective tissues of the eyelids favor exudation and 
edema. An abscess occurring here is usually due either to traumatism, 
or to septic infection entering from the face or scalp, or to periostitis 
of the margin of the orbit. Early treatment of contusions m.ay pre- 



DISCOLORATIONS OF THE EYELID. 285 

vent not only the unsightly discoloration ("black eye") but also a later 
abscess. 

To prevent disc ol orations apply cooling or evaporating lotions 
or wring a gauze compress out of ice water and apply to the lid, re- 
newing the compress every two or three minutes. Do not allow the 
compress to cover the nose, else acute coryza may result. Apply in this 
manner for an hour and repeat every second or third hour for twenty- 
four hours. 

Arnica, 2 oz., may be applied, or 

Aquae, qs. i pt. 

Ammonii Chloride, i 
Alcohol, I 

Aquae, 10 

// discoloration appears, apply flannel cloths wrung out of hot water, 
for an hour at a time, three or four times daily, and follow with gentle 
massage for five to ten minutes. Before applying the heat it is better 
to smear the lid with vaseline. Ointment of yellow oxide of mercury 
is excellent to use with massage. If an abscess appears make an inci- 
sion parallel with the muscle fibers. Apply antiseptic, absorbent 
dressings. 

ABSCESS OF THE LACHRYMAL GLAND. 

Abscess of the lachrymal gland is rare, yet doubtless is often over- 
looked. It is seen in infancy, usually traceable to some of the infec- 
tious diseases. The abscess breaks into the superior cul-de-sac and 
recovery follows. 

ABSCESS OF THE EXTERNAL AUDITORY MEATUS. 

Abscess of the external meatus is extremely painful and alarming, 
but in fact not particularly dangerous. The meatus is closed by the 
swelling, but a stab with the point of the knife, or, if it is more deeply 
situated, an incision in the direction of the long axis of the meatus, will 
cause a speedy disappearance of the symptoms. Gentle douching with 
an antiseptic solution and, after drying, occlusion with absorbent cotton, 
will soon complete the cure. 



286 ABSCESS. 

ABSCESS OF THE PAROTID GLAND. 

An inflammation begins in the parotid gland, the result of local 
infection or secondary to an abdominal disease or injury (most fre 
quently involving the pancreas, perhaps), and nearly always suppura- 
tion follows. The severe forms are dangerous; happily, however, 
the pus, even if left to take its own course, works its way to the surface 
or points at the pharynx. It may burrow down to the anterior medias- 
tinum. The special dangers are meningitis, septic poisoning and throm- 
bosis. When the swelling is great, pressure interferes with the venous 
current and, as a result, cerebral congestion, headache and finally 
delirium ensue. The pus may open into the middle ear and infection 
by that route reach the brain. There may follow suppuration of the 
temporo-maxillary articulation. 

Treatment. — If, when the swelling first appears, a probe be passed 
into Stenson's duct and the gland be pressed from the outside, a few 
drops of pus may be squeezed out and this may serve to head off a 
general suppuration. If the entire gland becomes involved, hot anti- 
septic poultices should be applied to hasten the localization of the pus. 
As soon as redness and edema indicate the most probable situation of 
the pus, an effort must be made to evacuate it. Several important 
structures are to be avoided; Stenson's duct (a fistula is likely to 
follow its division), the facial nerve, the carotid arteries, the temporo- 
maxillary vein and other vessels of lesser importance may be 
wounded. 

If the anterior part of the gland is involved, the incision is made 
parallel with and below Stenson's duct. The skin and fascia are 
divided and retracted and an effort is made to burrow into the depths 
of the gland with a probe or grooved director. The pus follows the 
connective tissue laminx instead of the lobules of the gland and it is 
better, if possible, to avoid dividing the glandular substance. If 
the posterior and lower part of the gland is involved, the incision 
should be vertical with its center a little above and anterior to the 
angle of the jaw. The temporo-maxillary vein will be seen parallel 
with the incision near the surface of the gland. A drainage tube must 
be left in the deeper abscesses. 



TREATMENT OF DENTAL ABSCESS. 



287 



DENTAL ABSCESS. 

These painful affections are not to be neglected for they may lift 
up the periosteum and result in necrosis of the jaw. Left to itself, 
the abscess may point in the mouth, less frequently on the face. It 
begins in the alveolar process from infection from a carious tooth. 
It makes its appearance at the junction of the cheek and the gum. In- 
spection and palpation make the diagnosis. A cotton tampon soaked 
in 2 per cent cocaine solution is laid on the gum for five to ten min- 
utes, but analgesia will not be complete. Lift the cheek away from the 




M.H. 




y/^.y^i 



Fig. 223. — Dental abscess. 
(Veau.) 



Fig. 224. — Submaxillary abscess 
in contact with inner surface of 
the inferior maxilla. Af./f., Mylo- 
hyoid muscle. P., Platysma 
myoides. GLs.M., Submaxillary 
gland. (Veau.) 



gum as far as possible and with a sharp pointed bistoury, wrapped to 
within a half inch of the point, make a horizontal incision and cut 
down to the bone. There is nothing to fear and without getting deep 
one may fail. The patient may resist further effort or the field may 
be obscured by blood (Fig. 223). 

Order an antiseptic mouth wash (peroxide or glyco-thymoline, etc.) 
to be used every half hour at first and the pain will rapidly disappear. 
In more extensive subperiosteal abscess of the jaws, the same principle 
of procedure should be carried out 



266 ABSCESS. 

SUBMAXILLARY ABSCESS. 

Do not await fluctuation in acute inflammations in this locality. 
The pain, augmented by pressure, the brawny edema and diffuse 
redness are sufficient to demonstrate the presence of pus. The pus is 
not always easy to find for it is deep, often subperiosteal and in con- 
tact with the internal surface of the jaw and is generally due, in fact, 
to dental infection (Fig. 224). 




Fig. 225. — Incision of submaxillary abscess. Dotted line represents the 
facial artery. (Veau.) 



Local anesthesia is often sufficient. Locate the angle of the jaw. 
This is often difficult on account of the edema. A finger's breadth 
below, and following the body of the jaw, make a curved incision 
(Fig. 225) with slight downward convexity about three inches in length. 
Remember the point at which the facial artery crosses the body of 
the jaw, just in front of the masseter. Do not cut deeper than the 
skin, for this is dangerous ground. Now dissect with forceps and 
grooved director the subjacent tissues, making haste slowly and re- 



ludwig's angina. 



289 



newing from time to time the analgesia or injections as the patient 
complains of pain. 

Carry the dissection upward and inward toward the inner surface 
of the jaw, and with patience the abscess will be located. As it is 
approached, the tissues will be found more and more edematous and 
filled with serum. Having once cut into it, enlarge the opening, al- 
ways too small, by introducing and opening an artery forceps. Irri- 




// ^f 



Fig. 226. — Phlegmon of the floor of the 
mouth. The tongue is pushed to the oppo- 
site side and the spread downward of the 
purulent collection opposed by the mylo- 
hyoid muscle. GSh, sublingual gland. AL, 
lingual artery. CW , salivary duct. GGL, 
genio-hyo-glossus. GY , genio-hyoid. MF, 
hyo-glossus. D, digastric. (Veau.) 



Fig. 227. — Incision for phlegmon of 
floor of mouth. (Veau.) 



gate with sterilized water, insert one or two small drains, dress with an- 
tiseptic gauze and absorbent cotton and renew daily. The tempera- 
ture will fall rapidly. After five or six days the drainage may be dimin- 
ished and after ten days entirely removed. 



ABSCESS OF THE FLOOR OF THE MOUTH 

(Ludwig's Angina). 

This is a very grave, usually fatal condition, originating in strepto- 
coccic infection through the mucous membrane of the floor of the 
mouth. It more frequently occurs in adults though childhood is not 
exempt. Its tendency is to extend into the neck, following the cellular 
19 



290 ABSCESS. 

planes, and if the patient does not die early from septicemia, gangrene 
may occur. In a very few hours after the infection begins, the floor 
of the mouth becomes brawny, the tongue is thrust up against the 
hard palate, and breathing and swallowing markedly interfered with. 
If anything is to do good, it must be done at once (Fig. 226). 

Try the antistreptococcic serum — if it does no good, it will at least 
do no harm. In the meantime, operate. Frequently a general anes- 
thesia is indispensable. Make an incision a finger's breadth below 
the body of the jaw about three inches long so that it reaches beyond 
the median line (Fig. 227). If both sides are equally involved, make 
a bilateral incision. One may perhaps recognize the platysma but 




Fig. 228. — Deep incision for phlegmon in floor of mouth. G.s.M., submaxillary 
gland. M.H., mylo-hyoid muscle. D, digastric muscle. (Veau.) ■ 

the anterior belly of the digastric must be demonstrated and divided. 
Next expose the mylo-hyoid and divide completely (Fig. 228). 
Having now reached the sublingual space, you may find merely a serous 
exudate, characteristic of this form of infective inflammation. Do not 
stop until the mucous membrane of the mouth has been demonstrated, 
for otherwise one may mistake the submaxillary for the sublingual 
gland and not go deep enough. 

Douche thoroughly with peroxide, place two or three large drainage 
tubes, pack with gauze saturated with peroxide, and apply absorbent 
cotton. Renew the dressings and flushing three or four times daily and 
the serum injections as well. Possibly the patient will go on rapidly 
to death from septicemia. He is almost certain to do so without the 
operation. The drainage may be diminished toward the tenth day. 
Several weeks will be required for a cure. 



TONSILLAR ABSCESS. 29I 

ABSCESSES OF THE TONGUE. ' 

Abscesses of the tongue do not often occur, but when they do, may 
give rise to urgent conditions. They may develop suddenly with much 
pain, which may be variously reflected — to the ear, for example. 

The tongue may be so swollen as to fill the mouth and severely dis- 
turb respiration. The location of the abscess is to be determined by 
palpation. If it is at the base' of the tongue and pointing toward the 
surface, it is to be evacuated by a median longitudinal incision from 
behind forward and deep enough to reach the pus. There is no danger 
of wounding important structures if the incision follows the middle line. 
Leave a strip of gauze in the wound for drainage. Prescribe frequent 
antiseptic mouth washes. If the abscess lies under the tongue and 
points downward, the incision must be made along the floor of the 
mouth, if the mouth can be sufficiently opened and fluctuation de- 
tected. The ranine artery may be wounded. If the mouth cannot 
be opened it is best to operate from the outside, making a median 
vertical incision from the symphysis of the chin down, getting between 
the two genio-hyo-glossi muscles and following this crevice up to the 
under surface of the tongue. Drainage tube, antiseptic absorbent 
dressing. 

TONSILLAR ABSCESS. 

"Quinsy" is an acute suppuration in the tonsil or around the tonsil 
following acate infection of the gland. 

Often the suppuration occurs only on one side though both tonsils 
are inflamed. At any rate the two tonsils do not suppurate simulta- 
neously. 

The temperature is high, the pain extreme, there is difficulty in 
swallowing and perhaps in breathing. There may be edema of the 
glottis. Often there is difficulty in opening the jaws. After the ab- 
scess is well formed the soft palate is edematous and swollen. 

Pus begins to form about the third day after the attack. Previous 
to this an effort should be made to abort the abscess. Give calomel 
in small frequent doses and follow with a saline purge, and in the mean- 
time administer full doses of sodium salicylate. Phenacetine, two or 



292 



ABSCESS. 



three grains 'frequently, will make the patient more comfortable. 
Paint the tonsils and pharynx with argyrol once a day and use the 
peroxide spray (50 per cent solution) every two or three hours. Ap- 
ply hot antiseptic fomentations or poultices externally. 

If these measures fail to relieve the 
symptoms after the third day, it is 
almost certain that pus has formed even 
though fluctuation cannot be felt and it 
is best to make an incision, but this must 
be free. 

The operation is sometimes difficult. 
A geneneral anesthesia will be neces- 
sary if the jaws are locked. Open the 
mouth wide. A mouth gag is often 
necessary. Depress the tongue as much 
as possible. Swab the tonsil with a 10 
per cent solution of cocaine. With a 
sharp pointed bistoury (wrapped), make 
an incision in the soft palate just ex- 
ternal to, and parallel with, the anterior 
pillars and extending as low down as 
possible. If the pus flows freely, some of it may be swallowed, to pre- 
vent which bend the head down. Continue the spray and antiseptic 
mouth washes for a few days.. Whether pus is located or not, free 
incision gives great relief (Fig. 229). 




Fig. 229. — Tonsillar abscess 
cision shoiild extend as low as possi- 
ble. (Veau.) 



RETROPHARYNGEAL ABSCESS. 



These conditions are treacherous and dangerous because, (most 
frequent in infants) they may be overlooked and, bursting into the 
pharynxj may produce suffocation.. 

The pharynx is separated from the muscles covering the anterior 
surface of the bodies of the cervical vertebrae by a loose connective 
tissue. One or two lymphatic glands lie in front of the bodies of the 
upper two cervical vertebrae to either side of the middle line. These 
receive lymph (and infection) from the nasal cavities and their accessory 



RETRO-PHARYNGEAL ABSCESS. 293 

sinuses, the naso-pharynx, the Eustachian tube, the tympanum, and 
from the tissues lying on the bodies of the adjacent vertebrae. Septic 
conditions existing in any of these localities may be the source of the 
inflammation of these lymph glands, which may end in suppuration. 
These glands empty by several chains of lymph vessels into the deep 
cervical glands. 

The suppuration begins on one side usually, but rapidly spreads 
toward the middle line, where the tissues are loosest. The abscess 
may be behind the palate; it may be opposite the larynx; in either case 
almost out of sight. Usually, however, it is seated in the posterior 
wall of the pharynx, opposite the oral cavity. When situated there, 
it gives rise to fewest symptoms, and for that reason its development 
is insidious, and in the infant unsuspected. The constitutional dis- 
turbance may be slight. 

Obstructed breathing and hoarseness and a feeling of tightness in the 
throat may first suggest the difficulty. Inspection and palpation, al- 
ways necessary, are not always easy and, in the case of infants, some- 
times dangerous. Still, only by touch, with the finger in the mouth, 
can the exact conditions be determined. To prevent asphyxia or 
syncope, the main thing is to be rapid in the examination. To facil- 
itate this, the child must be prepared. 

It is seated on the assistant's lap with its face turned to the light, 
its arms and body encircled by a towel, its legs held firmly between the 
assistant's knees. Its mouth is forced open by pressing the cheeks 
between the teeth. The finger is passed to the back of the tongue and 
rapidly palpates the walls of the pharynx. It is not difficult to deter- 
mine the point of great swelling. 

Operation. — i. Have already prepared a sharp pointed bistoury 
wrapped with cotton close up to the point. The index finger in the 
mouth holds the tongue down and the bistoury is passed along the 
finger and plunged into the abscess in the middle line, that no blood 
vessels may be injured. This puncture is prolonged into an incision 
from above downward at least an inch, in fact as low as possible, that 
chances of a recurrence may be diminished. The patient is imme- 
diately inclined forward in order that the pus may pour out of the 
mouth (Fig. 230). 



294 



ABSCESS. 



If syncope or spasm of the larynx occurs, do not lose your head but 
proceed hastily to revive the patient by the ordinary means. Lower 
the patient's head, pull out the tongue and employ artificial respiration. 

As after-treatment, direct frequent irrigations or gargling with 
sterilized water. A peroxide spray may be used with good effect. 
Recovery occurs within a few days. 

If the abscess recurs, or in the first place is situated too far 
down for oral puncture (which may sometimes be done by passing 




Fig. 230. — Retropharyngeal abscess. (Veau.) 



a curved director over the base of the tongue and then downward to the 
top of the abscess), or the jaws are locked, it will have to be reached 
from the side of the neck, an operation much more difficult in every 
way. 

Operation. — 2. Turn the patient slightly to one side, resting the neck 
upon a cushion to make its lateral aspect prominent; the sterno-mas- 
toid is the guide. Make an incision about two inches in length along 
the posterior border of the sterno-cleido-mastoid, which is exposed 
after the skin and fascia are divided. Ligate the veins ; avoid the super- 



ABSCESS OF THE CERVICAL GLANDS. 295 

ficial cervical nerves; pull the sterno-cleido-mastoid forward and locate 
the scalenus anticus. Stick to the scalenus anticus, follow its anterior 
surface inward, displacing forward by careful dissection with grooved 
director, the common sheath of the great vessels and pneumogastric. 
The connective tissues are rather loose; the dissection is not difficult. 
Be on the watch for the spinal accessory nerve, which lies on the deep 
surface of the sterno-mastoid. Working inward in this manner 
reach the outer border of the longus colli which lies in the same plane 
as the scalenus anticus, and upon which lies the pharynx and the 
abscess. After opening and emptying, a drain must be left. Employ 
the usual dressings and after-treatment. Sometimes the abscess lies 
further forward and it will be necessary to go in front of the sterno- 
cleido-mastoid. After the skin and fascia are divided, the finger in 
the wound will be able to locate fluctuation and that will be the best 
guide in the subsequent dissection. It may be necessary to ligate 
several small veins. Retract the anterior border of the sterno-mastoid 
and with it the sheath of the common carotid, the internal jugular and 
pneumogastric; draw forward the thyroid, the larynx and trachea. The 
fascias are divided by blunt dissection until the abscess cavity is opened. 

ABSCESS OF THE GLANDS OF THE NECK. 

Acute suppuration of the lymph glands of the neck is quite frequent 
and originates in infective disorders of the areas drained by the glands. 

In treating these conditions, the source of the infection must not be 
overlooked. It is not always advisable to operate immediately even 
though suppuration is believed to be present unless, of course, the 
infection shows a tendency to become general. 

In the ordinary case, the pus may be very deeply located or outside 
the capsule of the gland. It is better under these circumstances to 
apply hot antiseptic poultices for twenty-four to forty-eight hours. 
The whole gland then becomes softened, the pus is easily evacuated 
and healing occurs rapidly; whereas a non-suppurating gland cut into 
may remain enlarged and indurated. Free incision is always out of 
the question as the many important structures of the neck have to be 
borne in mind. Use local anesthesia. In making the incision it is 



296 ABSCESS. 

usually best to follow the posterior border of the sterno-mastoid. 
Make an incision about two inches in length. When the muscle is 
reached, draw it forward with a retractor and with a grooved direc- 
tor search for the pus cavity; drain; use absorbent dressings. 

CHRONIC SUPPURATION OF THE CERVICAL 
GLANDS. 

There are various clinical manifestations of the tubercular processes, 
each of which demands a somewhat different treatment. It is assumed 
that the pus gradually accumulating, has burst through the fascia and 
has begun to bulge the skin. 

It is best to operate at once. The most careful asepsis should be 
maintained. The pus is evacuated by free incision and the abscess 
cavity wiped out with iodoform gauze. A 10 per cent solution of 
iodoform emulsion with glycerine is poured into the cavity (two or 
three drachms are sufficient^ and the wound sutured and treated as an 
aseptic wound, provided there is no evidence of secondary infection. 

ABSCESS OF THE BREAST. 

Abscess of the breast may be either parenchymatous, originating in the 
substance of the gland; or submammary, originating in the areolar 
tissues separating the gland from the pectoralis major. 

In either case infection nearly always begins at the nipple and follows 
the lymph vessels downward. The first form is usually due to staphy- 
lococcic infection, the second to streptococcic. These conditions are 
preventable in the greater number of cases and for that reason the nipple 
should be given special care both before confinement and during the 
first weeks of lactation. 

Even when the breast becomes "caked" and tender and there is a 
little fever, antisepsis at the nipple and hot antiseptic poultices to the 
breast may prevent abscess formation. Continued rise in temperature, 
slight chills, edema and pain, more or less localized, indicate the for- 
mation of pus, and immediate operation is necessary. A general anes- 
thesia is best for thoroughness, though the work may be done under 
local anesthesia. 



ABSCESS OF THE BREAST. 



297 



Under rigid asepsis, proceed to open up the cavity and always re- 
member, the earlier the better. An incision an inch or so long should 
begin near the nipple and radiate from it, as the spoke from the hub 
of a wheel. In this manner the least possible number of the milk 
ducts and vessels are divided (Fig. 231). 

The first incision goes through the skin and fascia and then the 
abscess cavity is sought for by blunt dissection with a grooved director. 
Still there is nothing to fear in cutting boldly down to the abscess. 
Explore the cavity thoroughly for there may be pockets leading off 




Fig. 231. — Abscess of the breast: Incision. (Lejars.) 



from the main cavity. Do not neglect this point. If it extends deep, 
make a counteropening at the base, being guided bythe director intro- 
duced through the first opening (Fig. 232). Pushing a forceps through 
the channel, it seizes a drainage tube which is drawn into place as the 
forceps is withdrawn. Dress with antiseptic gauze, which should be 
changed twice daily at first, care being taken not to disturb the drainage 
tube. 

If the temperature rises again after the second or third day, you 
will have to re-explore. A new abscess is in process of formation. 
After five or six days replace the first drainage tube with a smaller one. 



298 ABSCESS. 

The drainage tube can be entirely dispensed with after ten days or 
two weeks. 

The submammary abscess develops without edema or redness be- 
cause it underlies the whole breast. The condition can scarcely be 
mistaken, for the marked elevation of the whole breast, along with the 
constitutional symptoms point to the nature of the trouble. Make a 
curved incision following the base of the breast at its lowest part, di- 
viding the skin and fascia. With a grooved director, dissect through 




- D 



Fig. 232. — Abscess of the breast. Manner of making counteropening. D, Grooved 
director; P, Its point; B, bistoury cutting down onto the point of director. (Lejars.) 

the areolar tissues between the gland and the chest wall, working toward 
the center of the breast. These deep tissues are likely to be infiltrated. 
In this manner the pus is evacuated and the subsequent treatment wall 
be practically the same as that prescribed for the preceding form, 

^ AXILLARY ABSCESS. 

Three chains of lymphatic glands are found in the axillary space. 
One lies along the anterior fold of the axilla and drains the anterior 
thoracic region; one lies on the posterior axillary wall and drains the 



AXILLARY ABSCESS. 



299 



posterior thoracic region; one lies along side and externally is connected 
with the axillary vessels and drains the upper extremity. Axillary 
abscess usually results from inflammation of one or the other of these 
chains of glands, the infective agent having been carried to them from 
a distant point, such as the breast or hand, by the lymph vessels. 

The inflammation spreads from the gland to the adjacent areolar 
tissue and pus formation follows. Abscess may also form by extension 
of pus formation from the base of the neck. 

The most frequent sources of infection, probably, are the breast and 
the sebaceous glands in the skin of the armpit. Abrasions and small 




Fig. 233. — Cross section showing relations of axillary abscess. G F. Pect. major. 
P. P. Pect. minor. G. D. Latiss. dorsi. 5. SC. Subscapularis. G. D. Serratus mag- 
nus. (Veau.) 

boils in this locality must be treated with circumspection, lest they 
terminate finally in axillary abscess. The ordinary symptoms of in- 
flammation and pus formation added to the painful abduction of the 
arm, indicate the nature of the trouble. 

It is imperative to evacuate the pus promptly for the reason that it 
may burrow in various directions, usually upward toward the neck. 
The axillary vessels may be eroded. 

The incision will depend upon the location of the pus— that is to say, 
whether it lies under the pectoralis major or in the loose areolar tissues 



300 



ABSCESS. 



of the center of the space. Acute abscess more often lies in the first 
locality (Fig. 233); tubercular abscess in the latter. 

(a) Acute abscess (Fig. 234). — General anesthesia; place the patient 
on his back; abduct the arm as much as possible; and locate the border 
of the pectoralis major. Make an incision three inches in length 
along this line, cutting toward the thorax; expose the muscle border 
well; dissect along the under surface of the pectoralis major with the 
grooved director. In this manner you keep in front of the great 




Fig, 



-Incision for acute axillary abscess. The blunt dissection should follow 
the anterior axillary wall. (Veau.) 



vessels and nerves and will feel secure. When the pus once flows, 
enlarge the opening, and insert drainage tubes. 

To avoid the axillary structures, you must keep these two points 
in mind: (t) Make the opening large enough to see what you are 
doing — a blind stab in this region is exceedingly dangerous; (2) stick 
to the pectoralis major — the pus is in contact with its deep surface. 
Wash out the cavity and place two drains; use a gauze and absorbent 
cotton dressing daily for a week, after which remove the tubes, though 
the external opening must not be allowed to close until the cavity is 
eliminated. 

(b; Chronic abscess. — Incision. Begin in the middle of the floor 
of the space and follow the middle line away from the arm toward the 



PALMAR ABSCESS. 30I 

chest. In this direction alone is safety. In front are the long thoracic 
vessels; behind are the subscapular vessels; to the outside are the main 
axillary vessels and branches of the brachial plexus. The skin in- 
cision may occasionally divide a small artery, which will at first give 
some concern. It is best to divide the connective tissues layer by 
layer in the original line of incision. There is no danger if you keep 
in this line. Otherwise, the pus may be reached by Hilton's method. 
After the skin and fascia are divided, a dressing forcep is pushed up 
into the abscess cavity and the blades opened. Put in a drainage 
tube; use absorbent dressings; maintain a careful asepsis throughout 
the process of repair. 

PALMAR ABSCESS. 

These are always serious conditions, not alone on account of sepsis, 
but because the hand may be left permanently crippled or useless as a 
result of the destruction of tissue and inflammatory adhesions. 

Immediate evacuation of pus is imperative. If the pus is limited 
to the connective tissues of the palm, has not reached the tendon sheaths, 
the incision should be made over, and parallel with, the interosseous 
space in the region of the greatest swelling. 

If the tendon sheaths are involved, the incision should be made in 
the long axis of the metacarpal bone (see phlegmon, page 325). Whether 
the condition is a diffuse inflammation (phelgmon) or an abscess will 
be determined by the history of the case. 

In the case of abscess, make a longitudinal incision. The palmar 
arches are chiefly to be considered. Begin the incision just below a 
line drawn across the palm from the web of the thumb. Beginning 
nearer the wrist, the superficial palmar arch or the deep arch as well 
may be divided. Cut toward the fingers, making the incision suffi- 
ciently deep to go quite through the palmar fascia. Insert a drainage 
tube. Use antiseptic dressings, changing the dressings daily. (See 
also phlegmons.) 

POPLITEAL ABSCESS. 

Situated in the hollow back of the knee joint in the superficial fas- 
cia are a few lymph glands which may suppurate following an infective 



302 ABSCESS. 

process in the foot and leg. Situated still deeper beneath the deep 
fascia are other glands which may similarly suppurate. 

These may be described then as superficial abscess and deep abscess 
of the popliteal space. 

The superficial abscess may be opened simply by a vertical incision 
over the point of greatest swelling. There are no important structures 
likely to be wounded by a superficial incision. 

It is quite different with a deep abscess. The situation of a num- 
ber of important structures must be borne in mind. In the center of 
the lower half of the space lies the short saphenous vein; to the outer 
side lies the external popliteal nerve and running vertically through 
the center of the space, and deeply located, are the popliteal vessels 
and internal popliteal nerve. The space is roofed over by the dense 
popliteal fascia which is the chief factor in determining the direction in 
which the suppuration extends; thus the pus is more likely to point up 
in the thigh or down in the leg than in the integuments of the space. 

A popliteal abscess may likewise be the result of the extension of 
a suppurative process in the thigh. These abscesses must be opened 
without delay for the reason that the joint may become involved, the 
vessels may slough and there may be destruction of tissue. There 
may be permanent flexion of the leg due to scar tissue. 

Before opening a popliteal abscess the diagnosis must be confirmed. 
It has happened more than once that a popliteal aneurism has been 
mistaken for an abscess and incised, a mistake serious indeed for both 
patient and operator. 

Acute inflammation of the bursae must not be mistaken for abscess. 
These bursoe are found in the boundaries of the space, separating the 
tendons from the protuberances of the femur, tibia and fibula. 

Operatiofi. — Either general or local anesthesia may be used. Make 
a vertical incision in the center of the space, dividing the skin, the 
superficial fascia and the deep fascia successively. With the grooved 
director separate the fatty tissues filling the space; keep in the line of 
the original incision. The pus will usually be located before the depth 
of the vessels has been reached. Enlarge the opening in the connective 
tissues, irrigate, search for diverticula, insert a drainage tube and pack 
lightly around the tube with aseptic gauze. Apply absorbent dressings 



ISCHIO-RECTAL ABSCESS. 303 

and extend the leg on a posterior splint. This extension must be main- 
tained until the healing is complete to prevent flexion. 

PLANTAR ABSCESS. 

The deep fascia of the sole of the foot is especially developed. 
It extends as a broad, dense band from one end of the plantar arch to 
the other, from the os calcis to the base of the metatarsal bones. It 
is a broad band divided into three portions: outer, middle and inner. 
The central portion alone is of much surgical importance. Its anterior 
extremity is broken up into five slips, and each slip branches and forms 
an arch for a flexor tendon. 

The result of this arrangement is that here is a closed compart- 
ment between the fascia and the bones of the foot which is occupied 
by the muscles of the middle foot. Following an infection, pus form- 
ing in this compartment finds great difficulty in escaping. It burrows 
between the metatarsal bones and makes its appearance on the dor- 
sum of the foot, follows the flexor tendons backward to the inner 
ankle, or may escape through the small aperture for the arteries into 
the subcutaneous fascia. 

On account of the denseness of the fascia, the pain in plantar ab- 
scess is extreme, and for relief of this pain and to prevent destruction 
of tissue, an early incision is imperative. The incision should be made 
over the most prominent part of the swelling, its long axis correspond- 
ing to the long axis of the foot. 

The skin is divided and then the thick fatty tissues, until the white 
and firm plantar fascia is reached. After the fascia is divided, the 
dissection is completed with a grooved director until the pus cavity 
is located. In this manner no important structures are wounded. 
Wash out the cavity and insert a small drainage tube. It is important 
that the cavity heals from the bottom. 

ISCHIO-RECTAL ABSCESS. 

The ischio-rectal fossa is a wedge-shaped cavity, lying on either 
side of the rectum, between it and the pelvic wall. Its base is covered 
by the integument and its sharp edge is directed upward and corre- 



304 ABSCESS. 

sponds to a line drawn from the pubes backward to the spine of the 
ischium — the line of attachment of the levator ani muscle, the "white 
line" of the pelvic fascia. The levator ani muscle forms its inner 
boundary. The obturator fascia covering the bony pelvic wall forms 
its outer boundary. 

The fossa is filled with fatty tissue which seems to form a packing 
and support for the rectum, but which at the same time forms a site 
of "lowered resistance'' to infective agents. 

These infective agents gain access to the fatty tissues of the fossa 
through ulcerations or abrasions of the rectal mucous membrane or 
from similar conditions in the integument around the anal orifice. 
For the most part the bacteria follow the lymphatics which have their 
origin in these localities and which follov/ the branches of the inferior 
hemorrhoidal vessels through the fossa. 

The symptoms of acute abscess here are the ordinary constitutional 
symptoms in marked degree, accompanied by intense throbbing pain 
in the region of the anus. The skin becomes brawny and indurated 
but no fluctuation appears in many cases. 

The symptoms of chronic abscess differ only in degree, and are 
often so slight as to be entirely overlooked. Abscess of any kind in 
this locality, when diagnosed, should be evacuated without delay. If 
left alone it will eventually open into the rectum or through the skin 
if the patient should survive the general sepsis. But spontaneous 
evacuation is in every way to be avoided, if possible. A fistula is the 
inevitable sequel if the case is left to nature. 

This fistula, opening into the bow^el w^hether the abscess formed 
near the roof of the fossa or near the floor, is very likely to be just above 
the external sphincter. There the bowel wall is thinnest, and the 
fascias of the levator ani act as an inclined plane along which the pus 
moves toward that part of the bowel. 

The examining finger in the rectum in the case of abscess will nearly 
ahvays detect the threatened opening there and confirm the diagnosis. 

Operation. — General anesthesia; lithotomy position; antisepsis. 

The incision (Fig. 25 5 j four or five inches in length is made from 
before backward and inclined a little outward midway between the 
ischial tuberosity and the rectum. Remember that cutting too near 



PERI-RECTAL ABSCESS. 305 

the middle line, you may wound the rectum; too near the pelvic wall, 
you may wound the internal pudic vessels. Some small hemorrhage 
will follow the skin incision. It may be necessary to cut deeper along 
the same line and you may wound some of the branches of the inferior 
hemorrhoidal arteries, but that is not a serious matter. 

With a little patience, in this manner the pus is reached and it pours 
out, extremely fetid and often mixed with shreds of connective tissue. 

Enlarge the w^ound so that it may be inspected and explore it with 
the finger. Irrigate vigorously. Being assured that all the minor 
cavities are opened up, introduce a large drainage tube and pack around 




Fig. 235. — Ischio-rectal abscess. Incision. (Veau.) 

it with gauze. The dressing must be renewed daily at first. The tubes 
can be gradually v/ithdrawn. 

It is absolutely necessary that the wound heal by granulation from 
the bottom and this may be a matter of weeks, or even months. Of 
this the patient should always be forewarned. During this time the 
dressings must be carried out methodically. 

If a small opening is exposed high up in the cavity, through which 
pus drains, it indicates a peri-rectal abscess above the levator ani, 
dangerous because it may become a general pelvic cellulitis or peritoni- 
tis. Enlarge the opening by the introduction of a dressing forceps, 
irrigate and drain. 

These peri-rectal abscesses not involving the ischio-rectal fossa are 



3o6 ABSCESS. 

difl&cult to diagnosticate, but when once determined they must be 
opened in the manner already indicated. 

Again, the ischio-rectal abscess may have, unfortunately, already 
opened through the rectal wall. Make the skin incision as before and 
then an additional step is necessary. Push a grooved a director up 
through the abscess cavity and through the rectal opening and then, 
following along the grooved director, cut through the entire thick- 
ness of the rectal and anal walls, holding one finger in the rectum 
to guide the knife. It will look like a very long wound, and yet it has 
the excellence of favoring recovery and the avoidance of a fistula. 
However, under the most favorable circumstances, it may require 
several months to heal (Lejars). 

PERI-ANAL ABSCESS. 

These are much less serious than those of the ischio-rectal region, 
both with regard to prognosis and treatment. However, if neglected, 
they are likely to result in a fistula; even if not properly incised they 
may so result. The peri-anal abscess is in the glands surrounding 




Fig. 236. — Incision for peri-anal abscess. (Veau.) 

the anal margin and lies under the integument or mucous membrane. 
Local anesthesia is all that is necessary except for those who are timid 
and with them general anesthesia is indispensable. 

Puncture the tumor at its apex. The pus is foul smelling. Irrigate; 
explore the cavity methodically with a grooved director. There is 



PROSTATIC ABSCESS. 307 

nearly always an ascending diverticulum on the anal side which com- 
municates with the rectum. Having located the apex of the cavity, 
push the point of the director through the mucous membrane, in other 
words make a fistula if one does not already exist (Fig. 236). Divide 
all the tissues over the director, in this manner laying open the cavity 
and anal margin. Carefully wipe out the walls of the abscess and 
pack with iodoform gauze. As important as the operation is the ajter- 
treatment. This the doctor must attend to himself. The dressing 
must be made daily, washing and packing lightly. After each move- 
ment of the bowels, the wound, must be washed and the packing re- 
placed, if possible. It is essential that the cavity granulate from the 
bottom. Repress excessive granulation with tincture iodine. 

PROSTATIC ABSCESS. 

The prostate gland, about the size and shape of a chestnut, lies 
at the base of the bladder, clasping but not quite encircling the first 
portion of the urethra. The upper surface of the urethra is covered 
by fibrous tissues which connect the upper surface of the two lateral 
halves of the prostate, so that the urethra apparently makes a tunnel 
through the prostate. The ejaculatory ducts empty into this portion 
of the urethra. 

The prostate is in contact with the second portion of the rectum 
one and one-half to two inches from the anal orifice. The apex rests 
against the triangular ligament, which separates it from the bulb of 
the urethra. 

Suppurative inflammation in the prostate originates from infection 
caught up by the lymphatics of the prostatic and membranous por- 
tions of the urethra. These infective agents are the gonococci, staph- 
ylococci, streptococci, bacilli coli communis. 

As might be expected, gonorrhea is the most frequent cause, both 
directly and indirectly. The passage of sounds, perineal bruises, sex- 
ual excesses and high living in one way or another favor the develop- 
ment of an inflammatory process which may result in abscess for- 
mation. 

The abscess may be limited to the gland substance or may develop 



3o8 ABSCESS. 

in the connective tissue surrounding the gland. In this case it may 
be called a pelvic abscess. 

Chronic prostatic abscess may be overlooked and unrecognized as 
the direct cause of many conditions: chronic urethral discharge; 
vesical and rectal irritation; rectal fistula; chronic inflammation of the 
prostatic adnexa (the ejaculatory ducts and seminal vesicles) ; suppurat- 
ing epididymitis and orchitis; nocturnal emissions. 

Any abscess of the prostate may open into the rectum, bladder, 
urethra, perineum or suprapubic region. Finally there is, in the case 
of acute abscess, the imminent danger of the general involvement of 
the pelvic fascia, ending in septicemia. It is manifest that a prostatic 
abscess is a constant menace. Its evacuation must not be delayed. 
It cannot be denied that oftentimes spontaneous evacuation is followed 
by a complete cure, but the outlook is many times more favorable with 
immediate operation. 

Diagnosis. — There is usually a history of gonorrhea, recent or 
remote. Fever and a few chills; violent perineal pain, radiating to 
the rectum and thighs; painful and difficult urination and defecation 
point to probable suppuration in the prostatic region. A little later 
perhaps the perineum is reddened, swollen and infiltrated. Complete 
the diagnosis by introducing a well-oiled finger into the rectum, which 
will excite much pain. On the anterior wall of the rectum will be 
found a large unsymmetrical swelling, more or less clearly fluctuating, 
and which loses itself in a doughy tumor extending toward the sides 
of the rectum and the anus. Now must one operate even though there 
be some pus discharging through the urethra, having begun spon- 
taneously or following the passage of a catheter. Such drainage is 
quite insufiicient. 

There are two methods of operation: (a) the rectal route when 
the abscess is about to burst into the rectum; (b) the perineal route, 
under all other conditions. In either condition general anesthesia 
is indispensable. The perineum and its vicinity are carefully sterilized 
and the patient placed in the lithotomy position for the perineal incision. 

Rectal route: Place the patient on the right side, flex the left thigh 
on the abdomen and let the assistant hold up the left buttock. Dilate 
the anus and give the rectal mucosa a thorough lavage, washing 



PROSTATIC ABSCESS. 



309 



with soap and water and gauze, followed by an alkaline antiseptic 
solution. 

Retract the posterior wall of the rectu n with a Sims' speculum. 
The anterior wall will thus be exposed to inspection. Locate hy 
touch the thinnest part of -the abscess wall, for the tumor will not be so 
conspicuous to sight as it is to the touch. Without hesitation push the 
point of the knife one-half inch into the tumor. This is to be done 
by sight and not by touch. When the pus flows, enlarge the opening, 




Fig. 237. — Prostatic abscess: patient in lithotomy position; incision between bulb 
and anus extending laterally to the ischial tuberosities. (Veau after Pierre Duval.) 

cutting toward the anus. Make the opening at least an inch in length. 
Favor the flow by slight pressure, and finally irrigate. You may be 
satisfied with that, leaving no drainage but repeating the rectal flush- 
ing several times daily at first. If the cavity is deep and if there is 
considerable oozing, it is better to pack very lightly with aseptic gauze, 
which will be expelled with the first movement of the bowels. 

Perineal route: An incision one inch in front of the anus, transverse, 
slightly curved with convexity forward (Fig. 237). This incision di- 
vides the skin and superficial fascia — edematous, it may be. Separate 
the edges of the wound and identify, if possible, the muscular layers 
composed of the transversus perinei, the sphincter ani and accelerator 



3IO 



ABSCESS. 



urinae, which coming from the cardinal points, meet at the "central 
tendinous point of the perineum," which is to be next incised. If 
these structures are not recognizable, the bulb of the urethra covered 
by the accelerator urinae can at least be found. It is a prominence 
which the finger if not the eye will readily detect. Incise transversely 
through the middle of the transverse perinei (Fig. 238), or at least just 
behind the bulb. The transversus perinei artery will be divided. 




Fig. 238. — Prostatic _^abscess. Showing relation of structures concerned in opera- 
tion; in front the bulblof the urethra, on either side the erectors of the penis, trans- 
versely the transversus perinei which is divided parallel with its fibers. (Veau after 
Pierre Duval.) 



Now draw the bulb forward out of the way with a retractor and pull 
the posterior lip backward with an artery forceps. 

Make the third transverse incision through the layer now well ex- 
posed, viz.: the superficial layer of the triangular ligament, a dense, 
fibrous membrane. The abscess is now covered only by the deep 
layer of the triangular ligament and this is best opened up with the 
grooved director, working jordjard in order to avoid the rectum, which 
lies immediately behind (Fig. 239). 

As soon as the cavity is located, enlarge the opening with the forceps, 



PROSTATIC ABSCESS. 



311 



irrigate gently, place a drainage tube and use an absorbent dressing, 
which is to be removed each morning and evening and after stool. 

Irrigation and Drainage of the Seminal Duct and Vesicle. — ^Puru- 
lent accumulations in the seminal vesicles demand relief on account 
of the frequent urination, and other symptoms, which sometimes 
may be attributed to the prostate itself. 

Belfield, of Rush Medical College, accomplishes the relief of these 
conditions by drainage through the vas deferens. 




Fig. 239. — Prostatic abscess; showing relation to bladder and rectum and the 
muscular and fibrous layers to be divided. (Veau.) 



The vas deferens is caught between the fingers at the base of the 
scrotum and brought up against the skin and held by a half-curved 
needle passed through the skin under the vas. A half-inch incision 
under local anesthesia is then made over the vas; it is exposed and 
opened by a longitudinal or transverse incision. The blunted needle 
of a hypodermic syringe is then passed into the canal and the solution 
injected. The liquid traverses the vas and the ampulla, and distends 
the seminal vesicles. 

If necessary the vas may be stitched to the skin by a fine silkworm 
gut suture, and a fistula thus established, through which daily in- 



312 ABSCESS. 

jections may be made. By this means, too, the vas is made to serve 
as a drainage tube for the ampulla. 

A fine silkworm gut may be passed into the canal and left until the 
next injection. Belfield recommends the procedure for chronic gon- 
orrheal infections of the seminal canal; chronic pus infections in 
the elderly (often mistaken for enlarged prostate); for acute gonor- 
rheal spermato-cystitis; and for the abortion of threatened epididy- 
mitis. 

VULVAR ABSCESS. 

The labia majora are composed of areolar and fatty tissues, bounded 
on the one side by skin and on the other by mucous membrane.' These 
integuments have many sebaceous follicles and are exposed to various 
forms of infection and traumatism. Along these sebaceous follicles 
and the lymphatics, agents of suppuration may travel to reach the areo- 
lar tissues, which are so prone to yield to the attack. 

The traumatisms of accident and brutality, and excessive coitus 
are then the predisposing causes; the streptococci and gonococci, 
the specific agents of inflammation of the vulva, which may end in 
abscess. The suppuration takes on the diffuse rather than the cir- 
cumscribed form. The labium majus of the affected side is swollen, 
doughy, reddened, dry, and there are the other local and constitutional 
signs of suppuration. The skin, apparently more than the mucous 
membrane, is involved and the lesser labium, scarcely at all. In order 
to avoid general infection, or an ugly slough from spontaneous evacua- 
tion, the abscess must be incised immediately. The presence of pus 
can nearly always be determined by fluctuation. After careful anti- 
septic preparation, a vertical incision in the site of the greatest swelling, 
usually in the integument, will be sufficient. There are no vessels 
to fear. Ordinarily, a strip of iodoform gauze will furnish sufi&cient 
drainage. An absorbent dressing and rest will soon bring about a cure. 

VULVO-VAGINAL ABSCESS. (ABSCESS OF BAR- 
THOLIN'S GLAND.) 

Beneath the vaginal mucous membrane, near the junction of the 
lateral and posterior walls, between the lesser labium in front and the 



VULVO- VAGINAL ABSCESS. 



3^3 



triangular ligament behind, is Bartholin's gland, one on each side. The 
gland is normally about the size of a small almond, and is about one or 
one and one-half inches from the vulvar orifice. Its duct opens into the 
vulvar canal just external to the hymen or its remains, the carunculae 
myrtiformes. Its lymphatics empty into the superficial inguinal glands. 

Its relation of greatest surgical importance is with the venous plexus 
(the bulb of the vagina), which 
covers its upper half and which 
may be wounded by too free 
incision. As in the case of 
vulvar abscess, the cause of sup- 
puration is an infective agent, 
most frequently the gonococcus, 
which reaches the gland by way 
of the excretory duct. Excessive 
coitus is a predisposing cause. 
The symptoms at first are those 
of acute inflammation of the 
vulva or vagina; finally the 
symptoms become localized. 

On examination the vaginal 
orifice is found to be almost 
closed on account of the swell- 
ing, and the mucous membranes 
hot and dry. The examining 
finger detects on the affected 
side, a well-defined body vary- 
ing in size, perhaps no larger 

than a chestnut, perhaps as large as a hen's egg. It is clearly circum- 
scribed. The labium majus is only slightly edematous ordinarily, the 
lower part more so. The abscess must be incised as soon as fluctua- 
tion is present in the slightest degree. Several serious consequences 
may attend delay. The inflammation may folio v tie vaginal areolar 
tissues into the pelvis; there may develop a phlebitis, or sloughing of 
the veins, or lymphangitis, or what is more common, there may result 
a recto-vaginal fistula. 




Fig. 240. — Vulvo-vaginal abscess. 
Direction of incision. 



314 ABSCESS. 

Operation. — Cleanse the parts carefully under local or general an- 
esthesia, incise the tumor in the direction of the long axis of the vagina 
from within outward (Fig. 240). Incise thoroughly, as this is the 
means of securing the drainage that will prevent a fistula. The in- 
cision must not be deep near the vaginal orifice for fear of wounding 
the bulb of the vestibule. A strip of gauze will favor healing from 
the bottom of the abscess. The region should be frequently douched. 

PELVIC ABSCESS. 

Separating the pelvic peritoneum from the organs of this region 
are loose areolar tissues which are prone to suppurate when attacked 
by infective agents. 

Pelvic cellulitis usually begins as a lymphangitis, following the ab- 
sorption of bacteria from some pelvic focus, usually the fallopian tubes. 
A salpingitis is the most frequent cause of pelvic abscess. The ar- 
rangement of the fascia and organs is such that the inflammatory 
exudates gravitate to the cul-de-sac of Douglass. 

Left to its own course, the abscess may open into the vagina, rec- 
tum or bladder; less frequently through the abdominal wall, saphenous 
opening, pelvic floor, obturator foramen, sacro-sciatic foramen, or 
into the peritoneal cavity. 

Diagnosis. — The history usually given points to an attack of pelvic 
cellulitis, following an abortion or complicated confinement, or some 
pelvic or abdominal traumatism. The temperature remains about 
100° with exacerbations reaching 103° or 104°. There are all the 
symptoms of septic absorption. 

On pelvic examination you are able to define a mass bulging dow^n 
into the recto-uterine pouch. This taken with the fever and pain, and 
perhaps some edema of the vulva, points without doubt to the nature 
of the trouble. A colpotomy should be done as soon as possible. 
The instruments needed are a speculum, a vulsellum forceps, a long 
artery forceps or dressing forceps, curved scissors, a scalpel, an irriga- 
tor, drainage tube and iodoform gauze. General anesthesia is gener- 
ally necessary, though in the simpler cases local anesthesia will suffice. 
Lithotomy position; the thighs held well apart, the shoulders lowered, 
the pelvis slightly elevated. 



INCISION FOR PELVIC ABSCESS. 



315 



A careful antisepsis: Shave the vulva and disinfect the inner sur- 
face of the thighs, and the pubic region as well. Disinfect the vagina, 
rubbing it with soap and water first and being careful to reach every 
part of the mucous membrane, using the finger and sterile gauze. 
Finally irrigate with i to 2000 bichloride, or other antiseptic solution. 
Cover the outside parts with sterile towels. Now retract the posterior 
vaginal wall with a Sims' speculum. With the vulsellum forceps 
seize the posterior lip of the cervix and pull the cervix forward (Fig. 
241). You will now be able to see the site which is to be incised. 




Fig. 241. 



-Incision of the vaginal mucous membrane for abscess in the posterior 
cul-de-sac. (Veau.) 



The tumor may be conspicuous, the edema and fluctuation well de- 
fined; or nothing but some edema may indicate the presence of the 
deeper seated inflammation. Do not attempt a mere puncture, how- 
ever well defined the pus cavity may be. With a curved scissors, or 
scalpel, incise the mucous membrane of the vault of the vagina one 
inch behind the base of the cervix. Make an incision from side to side 
but do not approach too near the vaginal walls else the arteries there 
may be wounded. Enlarge the wound by stripping its edges back 



3i6 



ABSCESS. 



a little. The abscess wall is exposed and with a little puncture the 
pus will flow. However, it may be that the pus is higher up and sep- 
arated from the mucous membrane by thick and edematous areolar 
tissues, and this must not be taken for the abscess. From it will flow 
a serous fluid which must be accepted as a proof of pus higher up. 

With the finger, or an artery forceps, follow the posterior wall of 
the uterus upward. Do not dissect backward. The rectum is there 
(Fig. 242). Follow the posterior wall of the uterus to avoid danger. 
There is always some hemorrhage, in no wise dangerous. It may be 
necessary to dissect upward for an inch; it will seem further than it 
really is. 





Fig. 242. — Showing the uterus pulled 
down, preparatory to opening the 
abscess in the posterior cul-de-sac. 
(Veau.) 



Fig. 243. — Showing relations of abscess 
in the posterior cul -de-sac. Dotted lines 
represent drainage tube. (Veau.) 



When once the cavity is opened into, enlarge the orifice and with the 
finger make careful search for a secondary cavity. If you irrigate, do 
not employ much pressure. Do not pack the cavity with gauze. 
Introduce a long drainage tube to the top of the cavity. Its lower end 
must not protrude at the vulva (Fig. 243). Pack the vagina lightly, 
changing the packing every day without disturbing the drainage tube. 
You may wash out the vagina but do not use much force. Replace the 
drainage tube by a sriialler one about the tenth day if the temperature 
is normal. It is likely that it will be pushed out spontaneously, and 
if it cannot be reinstated and the temperature is normal, it is certain 
that it is no longer necessary. 

In the matter of drainage it may be preferable to follow the plan of 



DIAGNOSIS OF SUBPHRENIC ABSCESS. 317 

Miller, of New Orleans, who employs both tube and gauze. A tube 
is introduced and plain gauze is packed around it. The gauze is not 
all removed until after five days, after which the cavity is flushed through 
the tube. The tube is shortened as the cavity contracts, but seldom 
entirely removed under ten or fifteen days in large abscesses (New 
Orleans Med. and Surg. Journal, Sept., 1906). 

Remember that the original cause of the suppuration has not been 
removed and after the abscess has healed a specialist had better take 
the case in hand. 

SUBPHRENIC ABSCESS. 

A localized peritonitis is possible only in those localities not occu- 
pied by coils of small intestines. Such a locality is the subphrenic, 
which is moreover practically shut off from the rest of the abdominal 
cavity by the transverse colon and its meso-colon. This space is sub- 
divided by the longitudinal ligament of the liver into a right and left 
portion; the liver occupies the right; the stomach, duodenum, pan- 
creas and spleen, the left. Any of these organs may be the source of 
infection which starts an inflammation of the peritoneum, ending in 
suppuration. 

The liver will give rise to most of the cases involving the right and 
does so through various affections involving the gland, or its excretory 
apparatus. On the left side the stomach, or the duodenum, through 
the medium of perforating ulcers, may give rise to the trouble. How- 
ever, the most frequent cause of subphrenic suppuration, wherever it 
may be located, is appendicitis. The pus follows the ascending and 
then the transverse colon to reach this region. 

Sometimes it may be impossible to determine the original focus of 
inflammation, but usually the history of the case will sufficiently indi- 
cate it. For example, vomiting of blood followed shortly by the for- 
mation of such an abscess would undoubtedly point to perforating 
ulcer of the stomach or duodenum, as-the "fons et origen." 

Diagnosis. — You will have, then, usually, a history of some vis- 
ceral disturbance, followed very quickly (perforation of the stomach) 
by a chill, fever, malaise, pain in the upper abdominal pole. The 
symptoms are, to be brief, those of peritonitis anywhere. 



3l8 ABSCESS. 

Suspecting an accumulation in the region just below the diaphragm 
proceed to carry out a methodical examination by means of percussion 
and palpation. The quantity of pus may be so great, or so near the 
front, that the bulging of the abdominal wall may settle the matter 
without further examination. In obscurer cases it will be necessary 
to recall the normal limits of dullness or tympany of the various organs 
in order to determine the nature and degree of displacement. Re- 
member, too, that in all cases following perforation, the abscess cavity 
will contain gas, which will be another source of confusion. After 
all, in the typical cases the history, the symptoms of sepsis, and the 
local signs rarely lead one astray. Aseptic aspiration may finally 
determine the matter; one need not hesitate to aspirate several times. 

The great majority of patients not operated on die from sepsis. 
Left to itself the pus may open into the alimentary tract, or it may open 
through the* diaphragm into the lung and be coughed up. It may 
open through the abdominal wall. Any of these means of drainage 
are too doubtful. It is imperative to operate at once, otherwise it may 
soon be too late. The pus may be (a) near the anterior wall, or (b) it 
may be inaccessible from the front; the method of operating is different 
in the two cases. 

(a) If the epigastric region is bulging, the pus manifestly pointing 
in that direction and near the surface, an incision in the linea alba, or 
along the outer border of the rectus muscle over the swelling will be 
sufficient. When the pus has ceased to flow the cavity must be care- 
fully sponged out for there are usually collections in its deeper parts. 
A counter-opening in the loin may be required in addition to the anterior 
wound in order to secure sufficient drainage. Moynihan recommends 
the "cigarette'' drain, which may be well saturated with powdered 
boracic acid. 

After the cavity has been wiped out, and before the drainage is 
inserted it should be irrigated with normal salt solution, or peroxide 
of hydrogen. The cavity must fill in by granulation which may re- 
quire six or eight weeks. 

(b; If the abscess is extra-peritoneal on the right side, an incision 
along the costal margin is perhaps best. Divide the muscles and then 
by blunt dissection, follow the under surface of the diaphragm until 



PSOAS ABSCESS. 319 

the abscess cavity is reached. Employ drainage, and, if desired, pack 
iodoform gauze about the tubes. 

In other cases it is best to employ the transpleural route (Fig. 2447. 
Begin with an incision five or six inches long over the eighth or ninth 
rib on the right side, or the seventh or eighth on the left. Expose and 
resect three and one-half inches of the rib in the axillary line. Deter- 
mine the condition of the pleura. If it contains pus open it up and 




Fig. 244. — Suphrenic abscess. Opening in the mid-axillary line. (Bryant.) 

work on through to the subphrenic abscess. If the pleura is not puru- 
lent, endeavor to prevent its infection by stitching the diaphragm to the 
chest wall and packing before opening into the abscess. The drainage 
and subsequent treatment are managed as described above. 

PSOAS ABSCESS. 

Psoas abscess is a term sometimes rather loosely applied to purulent 
collections in the iliac region. Properly speaking it is a tubercular 
abscess having its origin in caries of the lower cervical, dorsal or 
lumbar vertebrae. 

It is necessary to recall the arrangement of certain muscles and 
fascias. The psoas muscle, a rounded fleshy mass, lying along side 
the bodies of the lumbar vertebrae, extends across the pelvic brim and 
passes in front of the hip joint to be inserted into the lesser trochanter. 
The iliacus, its companion muscle, occupies the iliac fossa and con- 



320 ABSCESS. 

verges below in a tendon which merges with that of the psoas. These 
muscles are covered by the iliac fascia w^hich is so attached as to make 
the iliac fossa practically a closed compartment. 

The fascia is separated from the muscles by a loose areolar tissue 
in which suppuration may originate and which constitutes an iliac 
abscess. This fascia on its other side is separated from the perito- 
neum by another layer of connective tissue — the subperitoneal areolar 
tissue which is liberally supplied with fatty tissue and constitutes a 
site of lowered resistance to germs originating in the pelvic viscera, 
the cecum, the sigmoid and the appendix. Suppuration under this 
layer usually ends as a pelvic abscess. 

It is evident, therefore, that an iliac abscess beginning as such and ab- 
scess in the subperitoneal tissues are quite distinct from psoas abscess 
except that all have common points of -possible opening. The iliac 
fascia covers the muscles in the iliac fossa but it also extends upw^ard 
in such manner as to ensheath the psoas, and separate it from the 
bodies of the vertebrcT. 

In the case of caries, the products of decomposition may burst 
through the vertebral ligaments and the sheath and thereafter follow^ 
the psoas muscle downw^ard. The muscle itself may be decomposed 
in whole or part and the accumulating pus may be directed by the tub- 
ular sheath to its point of termination below Poupart's ligament to the 
outer side of the ihac vessels. Or, again, the abscess may burst 
through the sheath higher up and point in the loin (lumbar abscess;; 
or may point just above Poupart's ligament in the gluteal region, the 
pelvis, the scrotum, or thigh. 

The diagnosis of psoas abscess rests upon the history of the case, 
which points to spinal trouble, and upon the presence of fluctuating 
swelling in the iliac fossa, or below Poupart's ligament. Usually the 
hip is flexed in some degree, as by that position the tension in the 
psoas is relieved. 

This flexion and some apparent stiffness in the joint might lead 
to a mistaken diagnosis of hip joint disease. The swelling is to 
be distinguished, also, from a hernial tumor by the fact that it is fluct- 
uating and lies at the outer side of the iliac vessels. 

Treatment. — As in all cases of tubercular abscess, secondary 



OPERATION FOR PSOAS ABSCESS. 32 1 

infection and amyloid degeneration are most to be dreaded. For 
that reason spontaneous rupture and treatment by small incision and 
prolonged tubal drainage are equally dangerous. 

As early as possible an aseptic evacuation must be practised. 
This may be accomplished by puncture and the subsequent injection of 
iodoform emulsion; this seems the advisable procedure if the abscess is 
pointing in the region of Poupart's ligament and it is likely that the 
destructive process in the vertebra is in abeyance. In general most 
authorities recommend the operation of Treves, by the lumbar route. 

Operation. — Begin by locating the last rib, the crest of the ilium, 
and the outer border of the erector spinae. The incision, two and 
one-half inches long with its center half way between these bony land- 
marks, follows the outer border of the erector spinae .and exposes at 
first the lumbar fascia. 

Divide this first layer of the lumbar fascia and expose the erector 
spinae. Develop its outer border the w^hole length of the wound 
and retract the muscle inward, exposing the middle layer of the lumbar 
fascia. Divide this layer which exposes the quadratus lumborum. 

Divide the quadratus lumborum along the line of its attachment 
to the tips of the transverse processes, which exposes the deep or an- 
terior layer of the lumbar fascia. Divide this layer and finally the 
psoas magnus is exposed. Divide the attachment of the psoas magnus 
sufficiently to introduce the finger, which opens up the abscess cavity 
and determines the condition of the carious vertebra. 

The abscess cavity is to be treated by thorough irrigation with 
an antiseptic solution, wiped vigorously, or even curetted. The 
various layers are sutured without drainage and an aseptic dressing 
applied. 

Previous to suturing the cavity may be filled with iodoform emul- 
sion; or as Walsham suggests, after the cavity is cleansed it may be 
packed with strips of iodoform gauze, which are to be changed on the 
third or fourth days. If at the end of a week no pus has appeared 
and the cavity is lined with healthy granulations, the wound may be 
closed by secondary suture. 



CHAPTER XVIII. 
PHLEGMON: ACUTE SPREADING INFECTIONS. 

The areolar tissues are less resistant than others. The streptococci 
in their mode of development tend to spread out so that under favor- 
able circumstances the streptococcic infection of the subcutaneous 
connective tissues becomes one of the most dangerous conditions, 
demanding immediate and radical surgical intervention. 

The rapid development of toxins make death from septicemia to be 
feared; or short of this, there may be great destruction of tissue and 
subsequent loss of function. 

Certain regions, owing to the opportunities for infection and the 
arrangement of the tissues, are more likely to be affected than others, 
but the general symptoms and the principles of treatment are the same. 

One peculiarity of this inflammation is that pus is often slow to 
form, so that when the engorged tissues are incised in the earlier 
stages, merely a serum exudes. It is innocent looking but it is toxic 
in the extreme. 

The point then is this — do not wait for pus formation and fluctua- 
tion before evacuating these products. If pus has formed, immedi- 
ately is none too soon to operate. 

In the case of superficial phlegmon of moderate severity, it will 
often be harmless to try to localize the process by the use of hot anti- 
septic poultices or baths, but the safest thing is free incision for 
drainage. 

The incision must reach the deepest layer of the affected tissues, 
as anything less is useless; it may even be harmful by introducing a 
new infection to tissues which were not previously involved. 

Slight injuries with subsequent localized accumulations of pus 
are often the source of an infection which attacks the connective tissues, 
reaching them by way of the lymphatics, and then what was a mere 
local and harmless infection at first, becomes a very dangerous diffuse 
phlegmon. 

322 



PANARIS. 



323 



These minor conditions, therefore, are emergencies from the point 
of view of prevention. A few examples will serve to emphasize the 
principles governing their treatment. 

PANARIS. 

This is an infection involving the tissues about the finger nail. It 
may be limited to the epidermis, the dermis, the subcutaneous tissues 
or the periosteum, the last condition being usually called a felon. 

Panaris, Subepidermic. — The appearance at first is almost that 




Fig. 245. — Opening a purulent phlyctena or " run a round." (Veau.) 



of a blister, and all of the loosened tegument must be removed. No 
analgesia is necessary as the epidermis is non-sensitive. 

Begin by pricking the phlyctena with the point of the bistoury, and 
then trim around its whole circumference with pointed scissors (Fig. 

245)- 

Carefully observe the denuded surface and a small opening may be 
found, leading to a deeper cavity (button-hole abscess) which will 
require incision. 

^ Complete the treatment by a prolonged antiseptic bath and antiseptic 
dressing. 



324 



phlegmon: acute spreading infections. 



Panaris, Subungual. — In this form the pus accumulates under the 
nail and loosens it. It will be necessary to remove the part of the nail 
lying over the pus accumulation. A cure can be obtained only at that 
price. 

If it is confined to one side only, the skin is removed as described 
above, the sharp point of the scissors introduced under the nail, 
and enough of it resected to expose the suppurating surface. If both 
sides are involved, remove the nail completely. 

Panaris, Subcutaneous {Felon). — Incise as soon as pus is suspected. 
No harm can be done even if there is no pus, while a day's delay after 
pus has formed may make a great difference. 




Fig. 246. — Illustrating the situation of the pus in a felon; the dotted lines represent 
the limits of the incision. (Veau.) 



Under local anesthesia (Figs. 23c, 231), make a longitudinal incision 
in the middle of the palmar surface where the pain is greatest (Fig. 
246). 

Do not make a mere puncture, as the whole pus cavity must be 
exposed. Incise deliberately and let the first stroke cut long and 
deep enough, after which explore the cavity with a small probe. 

If there is a palmar prolongation, enlarge the opening, and if there 
is a dorsal prolongation, which is quite rare, make a counter incision 
on the dorsum of the finger. 

Immerse the hand in an antiseptic or normal salt solution for an 
hour. A drainage tube is unnecessary if the incision is properly made. 

Dress with moist antiseptic gauze and give the hand a hot bath 
with each daily renewal of the dressing. 

After two to eight days, or when suppuration has ceased, employ a 
dry dressing 



The dry dressing favors cicatrization but the moist 



dressing best rel 



leves pam. 






PURULENT TENO-SYNOVITIS. 



325 



SUPPURATIVE INFLAMMATION OF TENDON SHEATHS. 

Every neglected infection of the fingers or palm may become a 
phlegmon of the tendon sheaths. 

The great danger of these phlegmons is destruction or adhesion 
of the tendons so that the finger remains permanently flexed or ex- 
tended, unsightly and more or less 
useless. 

A threatened suppuration may 
often be prevented by a prolonged 
immersion in hot antiseptic or 
normal salt solution. This should 
be continued for an hour and used 
twice daily. 

As soon as pus is suspected, in- 
cise freely. Recall the anatomy of 
the parts (Fig. 247). The sheaths 
of the flexor tendons extend into 
the palm, whence the necessity of 
a palmar incision. The tendon 
sheaths of the thumb and of the 
little finger communicate with the 
common tendon sheaths in the 
palm, w^hence the additional gravity 
when they are involved. The com- 
mon sheaths extend from the palm 
under the annular ligament above 
to the wrist joint, whence the neces- 




FiG. 247. — Diagram illustrating the ar- 
rangement of the synovial sheaths in the 
hand. Note that the sheath of the tendon 
of the little finger communicates with the 
sheath common to all the flexors of the 
fingers in the wrist and palm. Note also 
that the sheath of the flexors of the thumb 
extends into the wrist beyond the annular 
ligament. The median nerve passes under 
the annular ligament between these two 
common sheaths. (Veau.) 



sity of incision in the forearm. 
There is in this incision an element 
of danger by reason of the median 
nerve, which lies on the middle of 

the front of the wrist between the two common sheaths. The ulnar 
artery lies on the common sheath on the ulnar side. The incision 
must pass between the artery and the nerve. 
Phlegmons of the sheaths of the first, second and third fingers are 



326 



phlegmon: acute spreading infections. 



not likely to extend further than the middle of the palm, while on the 
contrary phlegmons of the sheaths of the thumb and little finger 
are likely to point above the wrist. 

Operation for Phlegmon of the Synovial Sheaths of the Flexor Ten- 
dons in the Fingers. — A general anesthesia is usually necessary, for the 
pain is great. Make an incision about an inch long in the middle of 
the palmar surface over the point of greatest swelling. Incise to the 





Fig. 248. — Suppuration of digital 
synovial sheath. Incisions. (Veau.) 



Fig. 249. — Opening into the upper part of 
the ulnar synovial sheath. (Veau.) 



bone to be sure of opening the tendon sheath. The wound must be 
of uniform length in the superficial and deeper tissues (Fig. 248). 
If necessary make a similar incision over each of the phalanges and 
in the palm, but avoid opening into , the joints. If the sheath is dis- 
tended with pus, a drainage tube is easily passed through from one in- 
cision to the other. 



DRAINAGE OF ULNAR SYNOVIAL SHEATH. 



327 



When the pus has been located, immerse the hand in a hot normal 
salt solution for an hour and repeat twice daily. This greatly favors 
the evacuation of pus and subsequent repair. 

Employ moist antiseptic dressings at first. 

Operation for Phlegmon o] the Ulnar Synovial Sheath. — Continuous 
with the synovial sheath of the flexor tendon of the little finger, the 
ulnar synovial sheath is larger than the radial and its suppuration 
more serious. 

These phlegmons are usually consecutive to neglected infections 
of the little finger. 

Complete drainage is indispensable. 
Begin by making an incision over the 
radial border of the minimal meta- 
carpal (Fig, 249). Avoid wounding 
the palmar arch, which might require 
ligation; but after all this is not a 
serious accident and permits a freer 
incision. 

When the pus is reached, enlarge / \ // y 
the incision so that the tendon may / /vv^ 
be seen the entire length of the wound./ / \ 
Superficially and deep, the incision\ j 

must be of the same length. I / ^ ^^^- 

Next introduce a grooved director \y I // 
into this incision and push it through // 

the synovial cavity until its point, Fig. 250.— Drainage of phlegmon of 
- . IT the ulnar synovial sheath. (Veau.) 

passmg under the annular ligament, 

can be felt beneath the skin of the wrist. Incise carefully over 
this point until it is exposed, keeping to the inside of the tendon 
of the palmaris longus to avoid the median nerve. When the point 
of the grooved director is fully exposed, enlarge the incision, to an 
inch and a half. 

No artery of importance will be wounded. Pass a drainage tube 
through from one incision to the other (Fig. 250). 

Operation jor Phlegmon of the Synovial Sheath on the Radial Side. 
— The palmar incision may be made through the muscles of the 




32< 



phlegmon: acute spreading infections. 



thumb along the line of the metacarpal, but it is preferable to make 
it in the commissure between the thumb and index finger. 

Make an incision two lingers' breadth in length. At the depth 
of one or two inches you will find the pus. Pass a grooved director 
along the sheath as in the preceding case. It emerges beneath the 
skin above the annular ligament. Locate and expose the point of the 




Fig. 251. — Drainage of the radial synovial 
sheath. (Veau.). 



Fig. 252. — Drainage completed. 



director; in incising keep to the outside to avoid the median nerve. 
The radial artery is in no danger as it is too far to the outside (Fig. 251). 
In the same manner as before, pass a drainage tube. Immerse 
the hand twice daily for an hour in hot normaPsalt solution and 
employ a moist antiseptic dressing. The drainage tube will probably be 
unnecessary after the eighth or tenth day (Fig. 252). 



OPERATION FOR PHLEGMON OF THE FOREARM. 329 

SUB.\PONEUROTIC PHLEGMON OF THE FOREARM. 

By direct infection or by extension of infection from the hand, the 
areolar tissues beneath the fascia of the forearm may become the site 
of a diffuse suppurative inflammation. 

If neglected it follows the connective tissues into the intermuscular 
spaces and finally all the soft parts are more or less involved.' Free 





Fig. 253.— Incising the forearm for deep Fig. 254.— Note manner of fixing tubes 

phlegmon. The grooved director search- in drainage for phlegmon of the forearm, 

mg tor posterior prolongations of the pus (Veau.) 
formation. (Veau.) 

incision must be resorted to without delay. In the earlier stages no 
pus will be present but a straw colored serum pours out along the 
hne of incision. 

Operation. —General Anesthesia. Over the site of the greatest 
swelling make a free incision in the long axis of the member. This 
incision will traverse a thick, infiltrated layer to reach the aponeurosis, 



330 phlegmon: acute spreading infections. 

which incise carefully, when, in most cases, the pus will pour out. 
Enlarge the opening sufficiently on the grooved director. 

Irrigate thoroughly with hot normal salt solution and mop out with 
sterile gauze. With a grooved director explore all the parts of the 
cavity for a diverticulum (Fig. 253). 

If necessary make a counteropening. Tie such of the larger ves- 
sels as are divided and place several large drains (Fig. 254J. Change 
the dressing twice daily, irrigating each time with hot normal salt 
solution. 

About the eighth day, smaller drains may replace those first em- 
ployed and these are usually unnecessary after two weeks. Watch the 
temperature closely. If it rises, there is a retention of pus, the site 
is not sufficiently drained, or there is a new infection. 

DIFFUSE PHLEGMON OF THE ARM. 

All the soft parts are involved and infiltrated with serum. The 
arm is greatly swollen, edematous, and there are marked symptoms 
of septicemia. 

General anesthesia is indispensable. The freest kind of incision, 
even down to the bone from above downward, is essential. Three or 
four such openings are not too many. 

Irrigate freely with hot normal salt or bichloride solution. Moist 
antiseptic dressings should be used and at first should be changed 
several times daily. 

Incision with the Thermo-cmUery, Lejars. — With the thermo-cautery 
make several large incisions in the axis of the member, each at least 
four fingers' breadth in length and about two fingers' breadth apart 
(Fig. 255). Under the skin will be found a thick layer, infiltrated 
with bloody serum. Cutting through this the aponeurosis appears, 
which incise and thus expose the muscles. 

On the inner side avoid the vessels. If some of the large subcutane- 
ous vessels are opened and bleed too freely, tie them. Irrigate and 
dress with sterile gauze saturated with peroxide of half strength. 

Change the dressing and irrigate two or three times daily. Change 
to dry dressings when granulation is well under way. Later, skin 



SYMPTOMS OF PHLEGMON OF THE NECK. 33 1 

grafting may be necessary. In the long time necessary for repair, 
massage and passive motion must be given the muscles. 

PHLEGMON OF THE NECK. 

An infection in the floor of the mouth may become diffuse and 
spread rapidly down the neck. The symptoms of sepsis will be 



Fig. 255. — Incising a phlegmon of the arm with the cautery. (Veau.) 

aggravated in the extreme and death may rapidly supervene, either 
from sepsis or asphyxia. The whole neck may be brawny and edem- 
atous and the patient's condition is pitiable indeed. 



332 phlegmon: acute spreading infections. 

Lejars recommends the thermo-cautery as offering the best hope 
of a cure, though seemingly brutal. 

Under general anesthesia several deep vertical incisions are made 
with the thermo-cautery with numerous punctures between (Fig, 256;. 
Do not go too deep over the anterior border of the sterno-mastoid 
for the great vessels are there. 

Pack each incision and puncture wath gauze saturated with peroxide 




Fig. 256. — Manner of incising phlegmon of neck with the cautery. (Veau.) 

of hydrogen and cover the whole with a similar dressing and absorbent 
cotton. The dressing must be kept saturated with the peroxide. In 
the meantime use the antistreptococcic serum. 

Watson Cheyne also urges the use of the serum but does not use the 
thermo-cautery. His plan is to incise through the deep fascia in 
several places, enlarging the openings by blunt dissection. The 
wounds are to be freely sponged with undiluted carbolic acid, pow- 
dered with iodoform and packed with strips of iodoform gauze. 



CHAPTER XIX. 
ACUTE OSTEOMYELITIS. 

This is an acute infection of great gravity, more often due to the 
staphylococcus or the streptococcus, but in rare instances the pneumo- 
coccus, bacillus coli communis or tubercle bacillus may be the ex- 
citing cause. 

Usually the germ reaches the site through the blood current; at 
other times, leaving a primary focus which is perhaps unsuspected, 
it reaches its destination by way of the lymph channels or by continuity 
of tissue. For the germ to gain a foothold, there must be a lowered 
resistance or an impaired nutrition. The predisposing causes are 
found in certain constitutional states and in traumatism. 

The diagnosis is not always easy in the beginning, as the constitu- 
tional symptoms may be marked before the local signs are quite definite. 

Rheumatism does not have the symptoms of sepsis, though indeed 
the fever may be high. The pain is usually in the joint and usually 
in more than one joint. 

Arthritis likewise involves the joint, although it is to be remembered 
that an arthritis may be secondary to osteomyelitis and overshadow 
it clinically, but the history of the case will usually decide between 
arthritis and osteomyelitis. 

Erysipelas may be thought of when, after a little while, the skin 
becomes brawny and edematous, but in erysipelas the skin is so in- 
volved from the first. 

The symptoms may seem to suggest typhoid fever, or other infectious 
fevers, but these may usually be ruled out by the absence of charac- 
teristic features. 

The symptoms of meningitis are often present, but by the time they 
arise, the local conditions point to the. nature of the trouble. 

The general symptoms are those of sepsis; high fever beginning with 
a chill, rapid pulse, foul tongue, profound prostration and finally 
delirium. 

333 



334 



ACUTE OSTEOMYELITIS. 



Locally the pain over the affected area is extreme, and the least 
pressure tends to aggravate it. Gradually, as the inflammation 
spreads from the marrow through the bone to the periosteum, the 

skin begins to swell, redden, become 
edematous and finally shows fluctua- 
tion. 

In the virulent cases not operated 
upon, the patient dies within the first 
few days, from septic infection. In 
the milder cases even, large areas of 
the bone necrose. 

The treatment, then, must be 
prompt. It is an emergency. There 
is only one thing of any use to be 
done. The suppurating marrow must 
be evacuated and the medullary canal 
freely opened and cleaned out. Local 
applications, poultices or even incisions 
through the periosteum are illusory. 
The bone must be trephined, its cavity 
opened up at its most accessible part 
and all the inflamed tissue scraped 
away. The whole extent of the canal 
may need to be opened, irrigated, 
drained, and treated with vigorous 
antisepsis. 

Mosetig-Moorhof 's * iodoform- 
plombe or filling is applicable to such 
cases as these. It is prepared as 
follows: 

Equal parts of spermaceti and 
sesamoil are melted in an evaporating dish, then filtered into a 
Florentine flask and . sterilized in a water bath; forty grammes of 
finely powered iodoform (not crystallized) are put into a sterile 
flask, and sixty grammes of the hot fat mixture are added, under 
* Surgery, Gynecology and Obstetrics. Vol. Ill, No. 4. 




Fig. 256. — Exposing the tibial crest, 
opening into the subperiosteal ab- 
scess. (Veau.) 



IODOFORM PLOMBE FOR BONE ABSCESS. 



335 



constant agitation. This agitation must be continued without in- 
terruption until the mass solidifies. The flask is closed with a sterile 
rubber stopper. Before using the plombe is to be heated in water 
bath to a little above 50° C. 

The bone cavity is most carefully prepared for the reception of the 
filling. Everything must be removed down to sound bone. The 
laws of gravity must, of course, be observed. in filling the cavity. If 
the cavity is large, it is advisable to fill it in several steps, letting the 





Fig. 258. — Trephining of the tibia: 
making the orifice. (Veau.) 



Fig. 259. — Enlarging the orifice and 
exposing the medullary canal. (Veau.) 



plombe solidify in one portion before any is poured in to another. 
The cavity must be dry before the mixture is poured in. This may be 
accomplished by sponging, by the application of adrenalin to oozing 
points, by hot air, etc. The course of healing after iodoform filling is 
aseptic as a rule. Sometimes the temperature rises within the first two 
or three days — so-called aseptic fever — which yields to a cathartic. 
The disposition of the sprouting granulations toward the solidified 
plombe varies between complete closure of the wound and healing by 
primary intention, and incomplete closure. In the first cases, absorp- 
tion of the plombe is effected through the steadily advancing granula- 



33^ 



ACUTE OSTEOMYELITIS. 



tions by vital phenomena; in the second, by partial displacement and 
expansion. 

OSTEOMYELITIS OF THE UPPER END OF THE TIBIA. 

Here the disease occurs more frequently and here, fortunately, is 

most easily operated upon. 

General anesthesia; special instru- 
ments: a mallet, a gouge, a periosteal 
elevator or rugine and curette. 

Begin by elevating the limb to 
empty the blood vessels. About the 
middle of the thigh apply an Esmarch 
tube. Do not apply an Esmarch 
bandage, beginning at the toe and 
extending upward, for that only 
spreads infection. 

On the right side, the incision com- 
mences at the level of the tuberosity 
and extends to the middle of the leg, 
following the sharp crest of the tibia 
just to its inner side. However en- 
gorged the tissues may be this first 
incision reaches to the bone (Fig. 257). 
Often by this first stroke, one opens 
into a pus cavity. Do not be beguiled 
l3y this into thinking the operation 
completed. This collection is to be 
evacuated and drained, of course, but 
there is another one in the central 
canal. Extend the incision to the 
limit of the loosened periosteum. With the rugine expose the anterior 
surface of the bone. A fistulous opening leading to the medullary 
canal may possibly be found. In any event, proceed to trephine. 

At the upper end of the incision make an opening ^vith the gouge 
down to the canal. The pus will be almost certain to flow, but it is 
often diflicult to distinguish from the marrow. 




Fig. 2O0. — Trephining of the tibia 
completed. Tubes in place. (Veau.) 






OSTEO-MYELITIS OF THE TIBIA. 337 

At the lower end of the mcision, make another opening (Fig. 258). 
If again pus appears, it is certain that the lowest limit of the suppura- 
tion has not been reached and you must lengthen the incision. Con- 
tinue to expose the canal until the full extent of inflammation has been 
exposed. It may require the removal of the whole anterior surface 
of the tibia, but you are engaged in saving life, so that bone is a minor 
consideration. Chisel away, then, all the anterior wall between the 
two limits of suppuration (Fig. 259). Curette vigorously the medul- 
lary canal down to firm and uninflamed bone, and especially curette 
the upper part, for there the suppuration is greatest. 

In the case of a child, the epiphyseal cartilage is quickly reached, 
and this one should try to avoid, since too free removal will end linear 
growth. 

Next irrigate with normal salt solution, mop out thoroughly with 
sterile gauze and pack with sterile or iodoform gauze. This is an 
important part of the operation and it must be carried out thoroughly 
and methodically. 

Drainage must now be applied to the subperiosteal areas of suppura- 
tion, using rubber drains in the manner indicated (Fig. 260). 

If the operation has been delayed, the muscles of the calf 
may be infiltrated with pus and will require drainage as in diffuse 
phlegmon. 

If there is serous effusion into the joint, it will require no especial 
treatment for it will gradually be absorbed as the osteomyelitis is 
cured. 

If the joint is suppurating, it is quite different and another operation 
is required (see operation for purulent arthritis). 

Over the trephined area, apply a moist dressing and change daily. 
As the exudate becomes less abundant, change to a dry dressing and 
change the packing in the canal every other day. Smaller drains 
may be inserted about the tenth day, and are removed entirely when 
the suppuration shall have ceased. 

As Veau says, this intervention is only the first act of a prolonged 
and tedious process and this the family should understand beforehand. 
After several months, it may be necessary to remove some necrosed 
bone and long after the cure appears complete, the trouble may recur. 



I 



33^ 



ACUTE OSTEOMYELITIS. 



OSTEOMYELITIS OF THE UPPER END OF THE HU- 
MERUS. 

Begin the incision a finger's breadth below the clavicle, following 
the axis of the humerus. Prolong it downward five or six inches. The 
incision will traverse the deltoid near its anterior border. Separating 
the lips of the wound, divide the periosteum and proceed to trephine 
and drain as in the preceding case (Fig. 261). 




Fig. 261. — Osteomyelitis of the humerus. (Marsee.) 



OSTEOMYELITIS OF THE LOWER END OF THE 
HUMERUS. 
Make an incision eight to fifteen inches in length in the line of, 
and ending below at, the external condyle. The incision will traverse 
the thick fibers of the triceps. Trephine and drain. If it is necessary 
to make an internal counteropening for a drain, remember the situa- 
tion of the ulnar nerve. If the whole bone is affected, the same prin- 
ciples are involved. The prognosis is exceedingly grave. 

OSTEOMYELITIS OF THE LOWER END OF THE FEMUR. If 

Make the incision along the antero-internal border of the thigh, 
traversing the fleshy vastus internus. 



OSTEO-MYELITIS OF THE FEMUR. 



339 



The femoral vessels are behind this line. The bone is deeply 
placed and the operation difficult, but trephine thoroughly. Drain 
the medullary cavity and the periosteal abscess (Fig. 262). 




Fig. 262. — Cross section showing manner of placing drains after trephining 
the femur. (Veau.) 

OSTEOMYELITIS OF THE UPPER EXTREMITY OF THE 

FEMUR. 

Make the incision along the outer surface of the thigh over the great 
trochanter. Divide the aponeurosis of the gluteal muscle, trephine and 
drain. 



CHAPTER XX. 
SEPTIC ARTHRITIS. 

Septic arthritis is acute purulent inflammation of the joints, due 
to the presence of an infective agent, more frequently the staph- 
ylococcus or the streptococcus. The infection may reach the joint 
through a wound, by way of the blood vessels, or through the lymph 
channels. 

This purulent inflammation follows, then, direct injury or is a 
sequel to various infective diseases such as typhoid fever, gonorrhea, 
scarlet fever or osteomyelitis; but by no means are all the joint inflam- 
mations following these conditions purulent. 

Purulent inflammations are to be distinguished from non-septic 
inflammation both by the symptoms and the physical signs. The 
symptoms are those belonging to sepsis, for here it exists in a high 
degree. The tongue is brown and the temperature is very high, the 
pulse is weak and rapid, there are the appearances of prostration and 
finally delirium ensues. The pain is extreme and aggravated by the 
least touch. With respect to the physical signs there is marked swell- 
ing of the joint and the skin is red and edematous, not only over, but 
above and below the joint, and fluctuation is usually to be detected. 

Treatment. — This is an emergency of the first rank. It is an in- 
tervention designed to save the function of the joint; and sometimes 
even life is threatened. 

There is but one indication once the diagnosis is made, viz.: — to 
open the joint by free incision and counterincision, that every part 
of it may be reached and drained. 

The most careful antisepsis is to be observed. The limb is to be 
as carefully cleansed as if no pus was expected. 

Scrub the skin over the joint (the knee, for example), the upper 
third of the leg and lower third of the thigh with soap and water and 
with ether and bichloride. Sterilized instruments are to be used; 

340 



ARTHROTOMY OP THE KNEE. 



341 



they are simple, a scalpel, a few artery forceps, some rubber drains 
and an irrigator. The whole aim is to secure ample drainage and 
subsequent antisepsis, and nature will take care of the rest. In certain 
of the joints, however, mere incision may not be sufficient and ex- 
cision must be added. 




Fig. 263. — Septic Arthritis. Incisions for drainage of the knee. (Veau.) 



Arthrotomy of the Knee. — Sepsis affecting the knee joint causes the 
knee to become enlarged, globular in outline, painful, reddened, 
edematous, with constitutional symptoms of sepsis. The operation, 
under general anesthesia, is very simple and without danger. The 
important thing is to open freely. Two incisions are to be made, one 
external and one internal (Fig. 263). 



342 



SEPTIC ARTHRITIS. 



External Incision. — Locate the lower border of the patella, and 
beginning a little below this line make an incision parallel with the 
external border of the patella and ending about two fingers' breadth 
above its upper border, which will be near the upper limit of the 
synovial sac. This incision traverses the integument and beneath it 
the firm aponeurosis of the vastus externus. As the joint cavity is 
reached, very often the pus spurts out with great force. 

Internal Incision. — On the inside, make an incision symmetrical 




Fig. 264. — Drawing the transverse drain into place. (Veau.) 

with the first but a little further removed from the internal border 
of the patella. The aponeurosis is here less firm but the synovial 
cavity is deeper; the swelling is usually greater on the inner side. 
Some of the fleshy fibers of the vastus internus are always divided. 
The cavity is not so easily reached as on the outer side. 

Drainage. — ^Place a large transverse drain (Fig. 264). But in some 
cases this is not sufficient. The lateral diverticula of the synovial 
sack must be drained separately (Fig. 265). For this two counter- 
openings are required, one on each side. Into one of the incisions 



ARTHROTOMY OF THE KNEE. 



343 




Fig. 265. — Cross section of knee joint showing that the transverse tube drains the upper 
part; the two lateral tubes the inferior part of the synovial sac. (Veau.) 




Fig. 266. — -Manner of making posterior counter opening for drainage 
of the knee. (Veau.) 



344 



SEPTIC ARTHRITIS. 



at its lower part, introduce forceps and push backward and dow^nward 
through the synovial sack at the level of the interarticular line (Fig. 
266). If it is an old arthritis, this is not difficult, but in the case of a 
recent effusion, the ligaments are tense and the articular surfaces are 
in contact so that the passagew^ay is quite narrow. 

When the forceps, pushed backward in this manner, bulges the 
skin, open the blades and between them make an incision one or twTj 




Fig. 267. — Septic Arthritis. Drainage of the knee complete. (Veau.) 



inches long. Through this opening in the forceps draw a drainage 
tube into place. Repeat the manoeuvre on the opposite side. 

It is better to make the counter-opening on the external side first 
as the ligaments there are less tense. The beginner is seldom success- 
ful in making the opening internally. He nearly always pushes the 
forceps backward at too high a level and the point engages in the 
tendon of the adductor magnus. It must be directed downward 



ARTHROTOMY OF THE KNEE. 



345 



and backward (Fig. 267). When the jomt is thus opened, irrigate 
freely with hot saline solution, reaching every recess of the joint and 
wiping with sterile gauze. Aim to clean the whole synovia. If the 
joint is putrid finish the irrigation wdth peroxide. Do -not suture the 
wounds. Employ a moist antiseptic dressing. Immobilize the 
limb on a posterior plaster splint. 
Subsequent 'Treatment. — Irrigate and dress twice daily for the first 




Fig. 268. — Puncture of the knee. (Lejars.) 



few days. However, if the temperature falls almost to normal and the 
pain ceases, do not be in a hurry to change the first dressing. 

If the suppuration diminishes about the end of the first week, put in 
a smaller drain in the same manner as before and employ dry dressings. 
Watch the temperature. A rise indicates a retention of pus and 
calls for new drainage. Endeavor to avoid ])ermanent fiexion of the 
leg, a matter of the greatest difficulty and of the greatest importance, 
for such flexion cannot be corrected. 



346 



SEPTIC ARTHRITIS. 



After the second week the lateral drains are removed and some 
days later the transverse drain. After a month if the inflammation 
is all gone, attempt passive motion; but it is almost a certainty that 
the joint will be stiff; still if it is stiffened in extension, there is no 
occasion for reproach. 

PU^XTURE OF THE KXEE JOINT. 

Occasionally it is desirable to empty the knee joint as in the case 
of a voluminous hemarthrosis or serous exudation. The same careful 



Fig. 269. — Artlirotomy of the ankle. Trace of the incisions, (Veaii.) 



asepsis is practised as for arthrotomy. Locate the upper external 
angle of the patella (Fig. 268). A little above and to the outside of 
this point plunge the trocar directly into the joint. The structures 
here are quite resistant but there are no vessels likely to be wounded. 
As the exudate flows out gently compress the joint to empty it. With- 
draw the trocar with a quick movement, apply a sterile dressing and 
bandage the knee in absorbent cotton. 



INCISIONS FOR DRAINAGE OF ANKLE JOINT. 347 

ARTHROTOMY OF THE ANKLE JOINT. 

This operation is not so frequently required as for the knee. Often 
local anesthesia will suffice. Make the first incision, two inches in 
length, over the anterior 'border of the external malleolus and reaching 
a little below its tip (Fig. 269). In the upper part of the incision, 
one may cut freely down to the bone, but in the lower part more care 
must be used. Some small arteries may be divided if one goes too 
deep. 




Fig. 270. — Septic Arthritis. Drainage of the ankle joint. (Veau.) 

In the middle of the incision, open the joint, enlarge the orifice 
and mop out the cavity. 

Introduce an artery forceps and carry it through the joint cavity 
to the opposite side and over its point make a counteropening (Fig. 
270). This opening should fall over the tip of the inner malleolus. 
As the forcep is withdrawn, it pulls a drainage tube into place (Fig. 271) 

Dressing and subsequent care are the same as in the knee. 



348 



SEPTIC ARTHRITIS. 



ARTHROTOMY OF THE ELBOW JOINT. 

Make a vertical incision three inches in length with its center over 
the outer border of the apex of the olecranon, dividing some of the 
fibers of the triceps and anconeus (Fig. 272). Puncture the synovial 
cavity at the middle of the incision and enlarge the opening to corre- 
spond with the incision. Push a forceps transversely through the 




joint at 
internal 
in close 
Draw 
sequent 

Make 
and the 



Fig. 271. — Septic Arthritis of ankle. Drainage placed. (Veau.) 

the upper level of the olecranon. Over its point make the 
vertical incision. Cut carefully,, for the ulnar nerve is here 
contact with the posterior surface of the inner condyle, 
a drain into place with the forceps. The dressing and sub- 
care is the same as that described for the knee. 

ARTHROTOMY OF THE WRIST. 

an extenal incision between the long extensors of the thumb 
extensors of the index finger, lines which may always be 



ARTHROTOMY OF THE HTP. 



349 



determined. Make a second incision on the ulnar side between the 
tendons of flexor and extensor carpi ulnaris. The two incisions may 
be connected by pushing through a grooved director. 

ARTHROTOMY OF THE SHOULDER. 

The joint may be opened by a vertical incision beginning at the 
anterior angle of the acromion process and cutting downward in the 




Fig. 272. — Septic Arthritis of elbow. Incisions for drainage. (Veau.) 



line of the bicipital groove, or the joint may be opened behind along 
the posterior border of the deltoid, splitting the tendons of the infra- 
spinatus and teres minor. 

ARTHROTOMY OF THE HIP. 

The Langenbeck incision may be employed. Expose the gluteus 
maximus in the line drawn from the posterior superior iliac spine to 
the great trochanter. Split the fibers of the muscle in the same line. 
Expose the gluteus medius and separate its fibers, expose and open 
the capsule. It may be opened anteriorly along the external border 
of the psoas magnus. 



CHAPTER XXI. 
FOREIGN BODIES. 

THE EYE. 

Foreign bodies lodged on the conjunctiva or cornea are painful and 
may soon provoke a conjunctivitis, more or less severe. 

The offending particle may be concealed under the lid or be im- 
bedded in the cornea. The latter is especially likely to be the case 
with those who have to do with emery wheels. 

The patient's sensation is a very poor guide in locating the object: 
if it is on the cornea, he is likely to be certain it is under the upper lid. 

Begin by inspecting the eye under a good light and at various angles. 
Pull down the lower lid, instructing the patient to look upward. Evert 
the upper lid. This is done by grasping the eye-lashes between the 
thumb and f ore-iinger and pulling downward, at the same time making 
pressure upon the tarsal cartilage of the lid with a pencil, stylet, or 
the opposite thumb. Instruct the patient to look downward. Com- 
bined with this pressure, the eye-lashes are now pulled upward and 
in this manner the lid is everted and exposed to inspection. The 
novice does better, perhaps, to stand behind the patient, but the 
specialist sits in front of the patient and turns the lid with one hand. 

If the foreign body is free, it is readily picked up with the point of 
the stylet wrapped with cotton, but if it is imbedded in the cornea, 
considerable curettement may be required to dislodge it. The in- 
strument must be sterile, otherwise corneal ulcer may follow the 
manipulation. In the case of nervous or sensitive individuals, or 
when the conjunctiva is much congested, the manipulation must be 
preceded by the instillation of a few drops of a 4 per cent solution 
of cocaine, w^hich should be fresh and must be sterile. Everything 
used must be sterile; hands, instruments, cotton and solutions. 

Following the extraction, direct the patient to wash the eye fre- 

350 



FOREIGN BODIES IN THE EAR. 35 1 

quently with boracic or normal salt solution, and if there is much 
congestion, bandage the eye for one or two days. 

If the foreign body has penetrated to the anterior chamber, the iris 
or the posterior chamber, the immediate treatment must be limited 
to such measure as will prevent infection — boracic irrigation and 
bandage — until the case can be placed in the hands of a specialist 
or until special text-books can be carefully consulted. 

It may be necessary to employ the "X-ray" in diagnosis in these 
cases. The extraction may require a delicate operation or the use 
of the electro-magnet, and finally the removal of the globe may be 
necessary. 

Chemical irritants should be removed by free irrigation. For lime 
in the eye, a solution of sugar in vinegar is recommended, the sugar 
forming an insoluble compound with the lime. A few drops are used, 
followed by free flushing w^ith water. 

THE EAR. 

The foreign bodies most frequently found in the ear are pebbles, 
shoe-buttons, peas, beans, pens, pieces of tooth-pick, pieces of cotton, 
etc., etc. 

Children may place these objects in their ears in play or innocent 
experimentations, or adults may meet wdth the accident, attempting 
to relieve an itching in the auditory canal. A tampon may be left 
in the ear by the doctor. The body usually lodges in the outer part of 
the canal and only reaches the tympanic membrane, after ill-advised 
efforts at extraction. 

The pain and discomfort are usually moderate and, as a rule, there 
are no very urgent indications for intervention. But if the object 
rests against the drum, the pain is severe and may even produce mental 
disturbance. 

The first thing to do, then, is always to confirm the diagnosis. The 
patient's belief in the matter must, under no circumstances, be accepted 
as final. There is only one way to confirm the diagnosis and that is by 
careful inspection of the whole canal if the object is not seen in the 
outer portion. 

Draw the external ear upward and backward and the tragus for- 



352 FOREIGN BODIES. 

ward. Under good illumination and with the aid of a head-mirror 
and otoscope, the drum is readily seen. If nothing can be seen, and 
provided there have been no blind efforts at extraction, it may be 
definitely concluded that the patient is mistaken. 

If, on the other hand, you locate the object, do not hurriedly intro- 
duce a forceps into the ear seeking to grasp the object, unless, indeed, 
it is of such a nature that it may be easily seized, for you v/ill almost 
always make matters worse, pushing it further into the canal. Re- 




FiG. 273. — Ear Forceps. 

member that however desirable it may be to empty the ear, there is, 
as a rule, no great urgency in the matter and you have plenty of time 
to take counsel with yourself (Fig. 273). 

In some cases a small hooked instrument may be cautiously pushed 
past the object and withdrawn, pulling the object out, or a small 
blunt curette may be similarly employed. Usually a large syringe 
is the proper instrument. Throw a stream of warm, sterile water 
into the ear with the purpose of forcing the body out by the 'Wis a 
tergo." 

To inject the stream properly, lift the pinna upward and backward 
as in inspection and direct the stream along the posterior superior wall, 
using moderate force. Use one syringeful after another until the 
offending substance is washed away or the patient is tired out. 

If you have failed, instill into the ear a few drops of glycerine or warm 



FOREIGN BODIES IN THE NOSE. 353 

oil, lightly tampon, and direct the patient to sleep on the affected side, 
returning the next day for another trial. The chances are greatly in 
favor of ultimate success without injury to the ear. 

In the case of a live insect in the ear, fill the ear with oil and sub- 
sequently the "cadaver" may be removed by irrigation. 

If "instrumentation" seems advisable, there must be no blind 
grasping for the object — it must be kept clearly in view. It has 
happened, in violation of this rule, that the middle ear has been in- 
vaded and the ossicles dragged out. Death has occurred from such 
manipulation, though the post-mortem showed that no foreign body 
had ever been present. 

In the case of children, instrumental extraction will, as a rule, 
require an anesthetic. If the ear has become much inflamed or the 
body pushed through the drum, the case is one for the specialist. 

On the whole, the practitioner might adopt the rule, that if left in 
the ear, untouched, the foreign body is less likely to do harm than 
rude and maladroit efforts at removal. 

THE NOSE. 

The catalogue of bodies, recorded as lodged in the nose, is long. 
Naturally, children are more frequently the subject of these mishaps, 
although lunatics and hysterical women may intentionally plug the 
nose. Occasionally, a foreign body previously swallowed, may be 
coughed up and lodge in the posterior nares. Pledgets of cotton 
and pieces of gauze, which have been used as tampons, may be over- 
looked and act as foreign bodies. 

In the case of the irresponsible, the presence of a foreign body may 
not be suspected, so few are the symptoms, until there develops a 
profuse sero-mucus discharge. There may be frequent attacks of 
sneezing and if the body remains long, the mucous membranes be- 
come swollen and perhaps the skin of the affected side also. There 
may be facial neuralgia. These foreign bodies should be removed as 
soon as possible, first having determined their nature, size, and situation. 

Begin by a careful examination of the anterior nares, and if this is 
not sufficiently instructive, examine the posterior nares by hooking 
23 



354 FOREIGN BODIES. 

the finger up behind the soft palate. The examination and removal 
are often facilitated by the use of cocaine, and in the case of children, 
a few whiffs of chloroform way be necessary. 

Chloroform is also the effectual remedy for animate foreign bodies, 
such as insects and maggots. Used in this manner, it is not inhaled 
but is shaken up with an equal amount of water and syringed into the 
nose before the two ingredients separate. 




Fig. 273 a. — Angular forceps for foreign body in the nose. 

A body lying in the anterior nares is usually readily removed by a 
mouth toothed forceps; or a curved probe or small curette may be 
necessary to dislodge it. An angular forceps is sometimess con- 
venient (Fig. 273a). In other cases, the obstruction maybe rem.oved by 
drawing a tampon through the nasal cavity from behind, as recom- 
mended by Sajous. 

If the body is lodged in the posterior nares, it is usually pushed 
backward into the pharynx, care being taken that it does not drop 
down into the larynx or esophagus. 

" In the case of infants, a small body may be removed by blowing 
forcibly into the mouth." (John J. Kyle). 

PHARYNX AND ESOPHAGUS. 

Many diverse objects may lodge in these passageways, either 
through ineffectual efforts at swallowing or by inadvertantly slipping 



TREATMENT OF FOREIGN BODIES IN THE PHARYNX. 355 

from the mouth. False teeth are often loosened and carried into the 
pharynx or esophagus during sleep. 

The point of lodgment, the immediate effect, the dangers, and 
the difficulty of removal, depend upon the size and shape of the 
object. 

The pharyngo-esophageal canal is narrowest behind the larynx, 
opposite the cricoid cartilage and the sixth cervical vertebra: at this 
point a large body is likely to lodge. A second constriction lies two 
and three-quarter inches further down, behind the 
left bronchus; and a third where the esophagus 
passes through the diaphragm. Larger bodies 
then, are liable to lodge opposite the larynx. 
Sharp and pointed objects, such as needles and 
fishbones, may anchor at any point without refer- 
ence to the caliber of the conduit. 

The immediate effects of the lodgment of a 
foreign body vary from instant asphyxia to merely 
slight difl&culty in swallowing. Later there may 
occur, even in the case of a slight obstruction, the 
dangerous conditions following infection — erosion 
of the walls, perforation of the bronchi or lungs, 
of the pericardium, the aorta or carotids — one has 
but to think of the numerous relations of the 
esophagus in the neck and thorax to understand 
how diverse the consequences of such spreading 
infection might be in various cases. 

Very naturally, the deeper down the object -p^^^ 274.— Horse-hair 
lodges, the greater the difficulty in locating and l{St£^- ' ^^^"^ ^"^ 
reaching it. 

Treatment. — Asphyxia due to occlusion of the lower part of the 
pharynx involving the larynx, demands immediate action. The 
patient is livid, gasping and struggling. Run the finger into the 
throat over the epiglottis, where the body may be felt and hooked 
out. If you fail in this, do not waste time in these cases of extreme 
urgency, trying tentative measures such as inversion, but do a 
tracheotomy, or laryngotomy in the adult (see page 372). After the 




356 FOREIGN BODIES. 

operation, the foreign body may be expelled spontaneously in the 
efforts of coughing or vomiting. 

In the less urgent cases, the first indication is to confirm the diagno- 
sis and definitely locate the object. The sensation of the patient is not 
sufficient index as to the presence and situation of an obstruction in 
the gullet. 

Inspect the mouth, the fauces and the tonsils. Palpate the region 
of the glottis and behind the soft palate. Palpate externally along the 
anterior border of the sterno-mastoid, pressing deeply to reach the 
esophagus, most superficial on the left side. Even if the foreign 
body is believed to be located in the neck, as a result of this palpation, 
it is better to make certain by passing an esophageal sound. 




Fig. 275. — Coin catchers. 

In certain instances, the "X-ray" will be invaluable. In the hands 
of the expert, the esophagoscope has proved to be useful. 

The presence and location of the foreign body once established, 
extraction is indicated. Inversion is illusory and emesis dangerous. 

If the body is in the pharynx, it may be seized with curved forceps 
or dislodged with the finger or an improvised hook. To employ the 
forceps, seat yourself before the patient, whose mouth is propped wide 
open. When the object is once seized, incline the patient's head 
forward as the forceps is withdrawm. If you lose your hold, rapidly 
withdraw the forceps and remove the mouth gag and often t-he loosened 
object will be coughed out. 

In the case of an infant, place the patient on its back with the head 
hanging over the edge of the table, thus preventing the body from 
dropping into the larynx. (Have everything ready for tracheotomy). 

In extracting a body from the esophagus, the greatest caution is 



FOREIGN BODIES IN THE ESOPHAGUS. 



357 



necessary to prevent laceration. Rough manipulation only aggravates 
the muscular spasm and these esophageal muscles are exceedingly 
strong. The esophageal forceps is used as in the pharynx. 

The horse hair probang (Fig. 274), introduced past the object, 
opened up and then withdrawn, often succeeds in removing an im- 
planted needle or fish bone. 

In the case of a coin or similarly shaped object a "coin catcher" 
may be employed (Fig. 275). Introduce the left index finger as a 
guide and pass the instrument along its posterior wall until the coin 
is felt, when the catcher is passed on beyond it. Now tilt the handle 
forward and slowly withdraw the instrument until assured by the 
sense of touch that the coin is engaged. 
Completely withdraw the instrument by 
steady, continuous, vertical traction. 
When the pharyngeal orifice is reached, 
it is necessary to accelerate the move- 
ment to achieve the final extraction 
(Lejars). (Fig. 276). 

If, in the course of the manipulation, 
the foreign body is dislodged and slips 
on down into the stomach, do not regard 
it as a calamity, unless the object is very 
pointed. Indeed, if the object is deeply 
located, is known to be harmless in 
character and extraction seems impossi- 
ble, an effort should be made from the 
first to push it on into the stomach wath 
the esophageal bougie. This should 
never be done if the character of the 

substance is unknown. No effort should be prolonged and above all 
else, no violence is permissible. Finally, if extraction fails and propul- 
sion into the stomach is out of the question, there is only one thing left 
to be done — an esopJiagotomy. 

In certain cases where the body is firmly implanted, or when it is 
pointed and dangerous to move, resort must be made to the operation 
at once. (See page 378.) 




Fig. 276. — Extracting a coin from 
the esophagus. (Lejars.) 



358 FOREIGN BODIES. 

LARYNX AND TRACHEA.* 

The air passage is frequently involved, an accident always of con- 
cern, often serious, and sometimes fatal. 

The bodies finding their way into the larynx and trachea are of 
great variety, fluid and solid, animate and inanimate; most often 
aliments perhaps, and after these, the list may be indefinitely extended. 

Children are more often the sufferers because of their habit of putting 
objects into their mouths at random. Many times particles of food 
" go the WTong way," the result of the patient's speaking or laughing 
during the act of swallowing: the epiglottis is raised inopportunely 
and the morsel drops into the larynx. Small bodies are inhaled in 
ordinary breathing. The accident sometimes happens during sleep, 
through the dislodgment of false teeth or something held in the mouth; 
it may follow an attack of vomiting or it may occur during some opera- 
tion about the mouth, and conditions such as anesthesia, which 
diminish the reflex irritability or motility of the larynx, favor it. 

The point of lodgment depends chiefly upon the size and shape of 
the object. Pointed objects, such as pins and fish bones, frequently 
stick in the supraglottic portion of the larynx; flat bodies, coins and 
buttons, usually lodge in the ventricles, w^hile small globular, heavy 
bodies descend into the trachea or a bronchus, usually the right. 

The symptoms and sequelae, and therefore the dangers, may be 
grouped under two heads, obstructive and inflammatory. 

(a) If the body is large and lodged in the larynx, asphyxia may 
be the immediate result and may be almost immediately fatal. Even 
small bodies may produce fatal asphyxia through reflex spasm of the 
glottis, though usually the reflex spasm subsides. Reflexly, also, 
coughing, sometimes violent, is induced and this may be the case 
whether the body lies in the larynx, trachea or bronchus. Sometimes 
the body may lodge between the vocal cords, thus preventing their 
closure and aflowing some air to pass so that life may be sustained 
for some time. 

If the body is lodged in the ventricles, there may not be so much 
obstruction, but there is hoarseness or aphonia and cough. 

* Quotations are from Von Bergman. 



TREATMENT OF FOREIGN BODIES IN THE LARYNX. 359 

If the body descends into the trachea, there may be no indication of 
obstiuction, but there is much reflex irritation, evidenced by pain and 
cough. If the body is light, it may move backward and forward in the 
trachea, following the current of air. 

If a bronchus is obstructed, a whole or a portion of the lung may 
collapse, evidenced by altered pulmonary sounds. 

(b) The body may become encysted if not removed, or inflamma- 
tion may ensue with the most diverse sequences, depending upon the 
location of the object: edema of the glottis, diphtheritic inflammation, 
abscess of the larynx, phlegmon of the neck, hemorrhage due to erosion 
of the large vessels or even of the heart, tracheitis, bronchitis, bron- 
chiectasis, pneumonia, gangrene of the lung, empyema, purulent peri- 
carditis, mediastinitis, or phthisis. 

Treatment. — Asphyxia demands immediate action; there is no time 
for examination and inquiry. Make a hurried effort to remove the 
body by passing the finger into the larynx, and if this fails, without 
further delay do a tracheotomy (see page 372). 

In the less urgent cases, one may be more deliberate, endeavoring 
to ascertain the character of the object and to locate the point of lodg- 
ment. The history of the case, the symptoms and the physical signs 
derived from auscultation, will furnish valuable information. 

Various procedures are recommended. 

'' Inversion and violent shaking of the body do not enjoy their formei 
popularity. Even the conservative Weist considers manipulation of 
this sort dangerous and only justifiable after tracheotomy." 

Still it does not seem likely that it can result in harm if the body is 
known to be small so that it may readily pass between the vocal 
cords. 

"The simplest way is to follow the suggestion of Sanders, and let 
the body hang over the edge of the bed and rest on the hands during 
the attack of coughing." " Generally speaking, emetics are unreliable 
and their use not without danger." 

If there is time, the laryngoscope may be of great aid in diagnosis 
and extraction, employing cocaine in the adult and chloroform in 
children. 

In the hands of the skilled, the bronchoscope often furnishes a happy 



36o 



FOREIGN BODIES. 



solution to the difficulty (Fig. 277). In cases less urgent, the "X-ray" 

may be used to locate the substance. 

But after all, tracheotomy or laryngotomy 
is the chief reliance of the practitioner left 
to his own resources, and he must be pre- 
pared for immediate operation while other 
measures are tentatively tried. Lejars 
urges that an attendent be at hand ready 
for instant operation as long as the body 
is known to be free in the bronchus or 
trachea. 

" It makes no difference what one's views 
are regarding tracheotomy in general; the 
fact remains that no physician wdll deny 
the necessity of this step when the danger 
of suffocation is great." 

" The author has become convinced that 
the danger of tracheotomy nowadays is 
insignificant compared with that of a 
foreign body in the air passages and does 
not hesitate even when the body is situated 
in the larynx, to remov^e the offending ma- 
terial through an incision should extrac- 
tion per vias naturalis be impossible." 

"Tracheotomy is positively indicated 
when the foreign body is movable in the 
trachea." 

In any case after the urgent symptoms 
have subsided, "operative interference is 
the special form of treatment most rational 
and the form of operation depends upon 
the situation." "If the extraction means 
laceration, it is justifiable to split the larynx 
itself or a sub-hyoid pharyngotomy may be 
indicated." 
treatment to which so many patients formerly 




"The expectant 



FOREIGN BODIES IN THE RECTUM. 361 

fell victim, is to be condemned. This method is only justifiable in a 
small number of cases, in which the body has fallen far down into the 
bronchus where it cannot be reached. 

" The death rate shown by statistics should not decide the question of 
operation: the clinical picture of the particular case and the unfortu- 
nate cases should guide the surgeon. Those that died after the opera- 
tion did not do so because they were operated upon, but because they 
were operated upon too late. In an individual case the doctor can 
never count upon spontaneous expulsion. Every hour the offending 
material remains in situ lessens the chances more and more, while 
operation furnishes conditions most favorable for its removal. Open- 
ing the air passages, then, is the most rational procedure except for 
the cases in which endolaryngeal methods can be used." 

RECTUM. 

The objects which have been removed from the rectum at one time 
or another, cover a wide range — bottles, pieces of wood, etc., pushed 
in to stop a diarrhea, to satisfy a perverted sexual impulse, or by the 
insane. 

It is scarcely necessary to indicate all the instruments and artifices 
which have been employed in their extraction, but it is helpful, a 3 
Lejars points out, to formulate certain general rules of procedure. 

The necessity of these formulae cannot be doubted when one con- 
siders the difficulties of extraction, often considerable, and the fre- 
quency with which the rectum is lacerated by misguided effort. 

Often the patient does not admit the nature of his difficulty, con- 
sulting the doctor on some other pretext, such as constipation or 
some rectal trouble quite different from the real condition. In the 
case of obscure trouble in the natural orifices, the doctor should be on 
his guard. If the nature of the complaint is admitted, proceed to a 
methodical examination and endeavor to get your bearings. 

Introduce a finger, which has been well oiled, into the rectum. 
Sometimes you will find the object just within the orifice, of such 
size and shape that it can be readily extracted with the finger or with a 
forceps without further trouble, but you cannot count too much on 
that. 



362 



FOREIGN BODIES. 



If the examination shows it to be lodged high up in the concavity 
of the sacrum, impacted and perhaps completely filling the rectum, 
make no effort at extraction, but prepare for a formal operation. 

Under a general anesthetic, put the patient in the lithotomy position 
with the thighs w^ell flexed, the hips elevated and the anal region in a 
good light. Dilate the anus with the fingers as completely as possible 
and then determine the exact "presentation" of the body. Introduce 
a Sims' speculum, passing it under the guidance of the finger, beyond 




Fig. 278. — Foreign body in the rectum, b. bottle; c. Coccyx. (Lejars.) 



the coccyx, and then retract as widely as possible. This is easily 
done in the young but may be difficult in the adult. 

When the coccyx is thus sprung back, the body must be seized and 
traction made in the axis of the outlet if the body is long (a bottle for ex- 
ample) and firmly fixed (Fig. 278). The fingers or forceps may be 
used. If you are dealing with glass, the blades of the forceps must 
be covered with rubber to prevent slipping. If the ends of the foreign 
body are pointed, and imbedded in the rectal wall so that traction is 



FOREIGN BODIES IN THE URETHRA. 



2>^2> 



dangerous, great care must be exercised. In some cases morcellation 
will be possible. 

If the coccyx cannot be retracted and serves as the direct impedi- 
ment, it will have to be resected. If the body has found its way up 
into the left iliac region into the sigmoid, it may possibly be worked 
down into the rectum by external manipulation. Finally in such a 
case laparotomy and opening the bowel may be the only means of 
relief. 

THE URETHRA. 

A piece of sound may be broken off in the urethra. Boys or the 
insane may lose various objects in the urethra, slate pencils, pipe stems, 
pieces of watch chain, etc. 

As a rule, the accident is not immediately disastrous, for generally 
the impediment to urination is not complete. The object should 




Fig. 279. — Urethral forceps of Collin (a), Leroy d'Etiolles {b), and Hunter (c). 



be removed as soon as possible and with as little irritation to the 
urethra as possible. 

It is necessary merely to enumerate some of the methods employed 
successfully in various cases, and each case must be treated on its 
own merits. Often the body may be easily reached and extracted 
with forceps (Fig. 279). In certain instances, it may be gradually 
worked forward by external pressure; or in urination the meatus may 



364 



rOREIGX BODIES. 



be pinched up and when the urethra is ballooned out by the pressure 
of the urine, sudden release may result in the body being washed out. 
In case the body is in the deeper part of the urethra, and considerable 
manipulation is necessary, pressure should be applied over the urethra 
on the bladder side of the foreign body, to prevent its being pushed 
deeper. A piece of hollow sound or catheter may sometimes be re- 
moved by passing a smaller sound down into its lumen; or the urethral 




Fig. 280. — Extracting a pin from the 
urethra by "version". Protruding'^the point 
through the skin. (Brj^ant.) 



Fig. 281. — Point grasped with forceps 
Its direction reversed and head brought out 
through the meatus. (Bryant.) 



speculum or a larger hollow sound may be passed down to and over the 
body, which permits its more ready seizure by a forceps passed through 
the speculum. 

Dayat shaped a lead sheet into the form of a hollow sound and, 
passing it beyond the object in the urethra, closed its lower end by 
pressure over the urethra and in removing the lead catheter, the 
foreign body came out with it. 

In another case, a stick forced into the urethra could not be with- 



FOREIGN BODIES IN THE URETHRA. 365 

drawn on account of a hook on its lower end, but after being split into 
many pieces, its extraction was accomplished piecemeal. 

In the case of a pin lost in the urethra head downward, its point 
may be driven through the skin and "version" accomplished and the 
head brought out through the meatus (Figs. 280, 281. 

In other cases it may be necessary to do an external urethrotomy, 
and finally the object may have to be pushed into the bladder and 
removed by suprapubic cystotomy. 



CHAPTER XXII. 
BURNS SCALDS AND FROSTBITE. 

From the point of view of prognosis and treatment, burns are of 
three degrees: 

(i) Transient application of heat, something below the boiling 
point, produces hyperemia. 

(2) A greater degree of heat or a longer application produces a 
more definite vaso-motor paralysis and there is exudation, particularly 
into the malpighian layer and the epidermis is lifted up in the form 
of blisters. 

(3) The albumen of the tissues and fluids is coagulated. This 
necrobiosis may be superficial or it may involve the deep structures 
as well. 

Symptoms. — Even in slight burns, pain is always a prominent 
symptom. In the severer burns, shock is always present in some 
degree and as the shock disappears, reaction comes on, with rise of 
temperature, and the symptoms resolve themselves into some form 
of internal congestion, or systemic intoxication characterized by 
hemoglobinuria or albuminuria, vomiting or bloody diarrhea. After 
a few days the symptoms may be those of septic infection. 

The cause of death from burns falls into four groups: 

(a) Shock. This may be rapidly fatal, sometimes as late as twenty- 
four hours. Death may be due to cardiac paralysis, the result of over- 
heating of the blood. 

(b) Toxemia. The tox-albumens resulting from the chemical 
changes in the tissues find their way into the circulation and over- 
whelm the heart and kidneys, usually within the first two or three 
days. It has been demonstrated that these toxic substances are 
hemolytic and cytotoxic for the parenchyma cells and are eliminated 
from the body by the kidneys and intestinal tract. 



PROGNOSIS IN BURNS. 367 

(c) Internal congestion and inflammation, involving the cerebral, 
thoracic or abdominal structures. 

(d) Septic injection or its sequelce. — This may be fatal after the first 
few days or only after a prolonged struggle. 

Factors Determining the Prognosis. — (a) Area and depth of burn. 

(b) Age and general condition of patient. 

(c) Region. 

(d) Degree of infection. 

The rules for determining the prognosis can be formulated only 
in a general way with reference to these various factors, and yet keep- 
ing them in mind, a quite definite forecast may often be made in a 
given case. 

(a) It is the area rather than the depth of the burn which deter- 
mines the danger. An extensive superficial burn is more dangerous 
than a limited but deep one. It appears that under the effect of heat 
muscular tissue generates a poison much less toxic than that from 
the skin. Mere reddening of two-thirds of the cutaneous surface 
will almost inevitably result in death, while destruction of one-third 
of the skin will probably produce the same result, yet most burns of 
the first and second class commonly met in practice will recover. 

(b) The age and general condition involve the question of the 
ability to rally from shock and to resist infection. By reason of their 
lack of resistance to these forces, the young or the aged may succumb 
to even slight burns of the third degree. 

(c) Burns over the head are dangerous for the reason that menin- 
gitis may develop, and similarly burns of the thorax and abdomen are 
likely to result in lesions of their contained viscera. Burns about the 
face are often accompanied by corresponding injury to the air passages 
by inhalation of smoke or flames. 

(d) The most important factor, however, in the process of severe 
burns is injection. Such injuries, in fact, are infected wounds. The 
coagulated albumens of the destroyed tissues are not favorable soil 
for the development of the bacteria, but around the circumference of 
the burn are tissues of lowered vitality which are not only unable to 
resist the encroaching germ but more than that, actually nourish it. 

The serous exudates of superficial burns are likewise culture media, 



368 BURNS, SCALDS AND FROSTBITES. 

SO that in severe burns as well as in other wounds, it may be said that 
the patient's fate lies in the first dressing. 

Treatment. — Slight hums of the first degree require protection, 
w^hich may be furnished by vaseline; by gauze saturated in boracic 
acid solution; by carron oil; by dusting powders of various kinds, 
boracic acid, dermatol, bicarbonate of soda, flour. 

In severe hums the indications are to combat the shock, to relieve 
the pain and to prevent infection. In the matter of the local treat- 
ment of these conditions, the final word has not yet been spoken. 
The most divergent opinions appear in current literature and of these 
various lines of treatment, perhaps none are wholly bad; certainly 
few are altogether good. 

Begin then by combating shock and relieving pain. These two 
conditions are usually relieved at once by frequent but small hypo- 
dermatic doses of morphia, supplemented by subcutaneous or venous 
injections of salt solution. If parts .beneath the clothing are involved, 
use the greatest care in removing so that the skin will not be removed 
with it. 

To cut the clothing is safer than to attempt to undress the patient. 
Always remember that contact with the clothing may be the chief 
source of infection. 

Now w^hat will one do to prevent infection? This is the chief 
problem. 

If the burn is of large extent and depth as well and has been in 
contact manifestly with sources of infection, there is but one thing 
to do if the aseptic method is to be employed. Anesthetize the patient 
after the shock has passed and proceed to sterilize the parts. Scrub 
the uninjured skin around the wound with soap and water and then 
alcohol and bichloride. Next proceed to irrigate the burned area 
with normal salt solution, in the meantime carefully rubbing with 
sterile gauze to the end that every bit of foreign matter may be removed. 
In those parts that are merely blistered, the blebs are to be punctured 
and the serum washed away. It may be advisable even, for the sake 
of thorough disinfection, to make no effort to spare the cuticle of the 
blisters in rubbing with the sterile gauze. 

Not hurriedly but patiently complete this cleansing. It will prob- 



TREATMENT OF BURNS. 369 

ably require from one-half to three-quarters of an hour, but it is time 
well spent. You have now to deal with an aseptic wound. 

Next cover the area with plain sterilized or borated gauze and over 
this apply absorbent cotton and bandage snugly. 

If much cuticle has been removed, cover with sterile vaseline before 
applying the sterile gauze. 

The aid of a splint may be required to prevent deformity. If no 
fever arises the dressing need not be changed for eight or ten days. 

It may not be practical to institute the thorough disinfection which 
anesthesia alone permits, but one can at least cleanse the adjacent 
area as before described. Prick the blisters and irrigate the burnt 
area vvith normal salt solution, but in this case sterilization is not 
so much a certainty. 

Therefore you must employ an antiseptic dressing. Whatever 
dressing you select should have these properties at least: it should be 
antiseptic, analgesic and keratogenic. A number of substances possess 
these properties in various degrees and are otherwise more or less 
unobjectionable. 

Picric Acid. — This is employed in solutions of i or 2 per cent. A 
good solution is made by dissolving one and one-half drachms in 
three ounces of alcohol and adding some of this solution to two parts 
of water. After cleansing the surface apply strips of sterile gauze, 
soaked in the solution, cover with absorbent cotton and bandage. 
Change the dressing in three to four days, soaking it loose with the 
same solution. 

Turpentine. — This is an excellent domestic remedy, antiseptic and 
analgesic but only to be employed in slight burns of the first degree. 
Cover the area with absorbent cotton and saturate with the turpentine 
and bandage. 

Aristol. — This, too, renders excellent service. Use as an ointment 
mixed with sterile vaseline or zinc ointment in the proportion of 
eight to ten grains to the ounce and apply spread on sterile gauze. 

The Ointment oj Feclus. — This, perhaps better than any other 
ointment, meets all the indications. It is applied in a thin layer 
directly to the surface or spread on sterile gauze and the dressing com- 
pleted with cotton and bandage. Here is the formula of the ointment 
24 



370 BURNS, SCALDS AND FROSTBITES. 

as modified by the author and prepared by the Pitman, Myers Co. 
and which should be ready for instant use: 



-Hydrarg. Chlor. Corros 


, I part. 


Acid Carbol., 


30 parts 


Aristol, 


30 " 


Acid Boric, 


90 " 


Salol, 


90 " 


Antipyrine, 


150 « 


Petrolatum, 


576 " 



Carron Oil. — This is an old and useful remedy, but, as ordinarily 
used, unqualifiedly to be condemned. It favors suppuration because 
it is in no wise antiseptic and perhaps may — indeed often does — carry 
infection. If the oil is sterilized and then applied to the surface 
which has been made as clean as possible, it is an efficient dressing. 

Granger, of Rochester, Minn, uses equal parts of lanolin and zinc 
ointment spread thickly on gauze, covering the ointment with the 
waxed paper sold by instrument dealers, and applying the dressing 
with the paper next to the burned surface. The dressing is next 
covered with a thin layer of cotton. He claims that it is soothing and 
easily removed. 

The frequency with which any dressing must be changed will 
depend on the pain or infection. If the secretions are excessive and, 
by drying and stiffening the dressing, aggravate the pain, the dress- 
ings must be frequently changed. 

If there is infection, the rise of temperature will be the index. 
The same care must be exercised in changing the dressings as in 
treating any other wound. 

BURNS OF THE MOUTH. 

Burns oj the mouth and air passages are not infrequent. These 
may be the result of taking hot substances into the mouth or the 
inhalation of hot gases in explosions. Pain and difficulty in swallow- 
ing are the most frequent symptoms. In addition there may be 
edema of the glottis or finally acute bronchitis may develop. Cold 
water and bits of ice give the most relief. The edema of the glottis 
may require tracheotomy. The various forms of inflammation such 
as bronchitis or pneumonia must be treated on general principles. 



TREATMENT OF FREEZING. 37 1 

ELECTRICAL BURNS. 

These are painful out of proportion to the lesion and require two 
or three times as long for repair. 

Begin with hypodermics of morphia and strychnia (^V). Cleanse 
the wound by the ordinary surgical method and dress with sterile 
gauze, cotton and bandage. 

FREEZING. 

The effects of very low^ temperature on the , tissues are practically 
the same as those of heat. The ultimate effect is death of the tissues 
or gangrene. 

The treatment of patients overcome by cold must be circumspect. 
The main point is to go slow in warming the parts. The patient 
should never be brought directly from out doors into a warm room. 
Sonnenburg advises that a cold bath, the temperature of the cold 
room, be used, and the temperature gradually raised until in two or 
three hours it reaches 80° Fahr. Where life seems extinct artificial res- 
piration should be practised and sometimes the circulation may thus 
be re-established. Subsequently hot rectal enemata of whiskey or 
coffee may be employed. The limbs and other frozen parts should 
be covered with moist compresses for the first forty-eight hours and 
then dusted with boracic acid and encased in a thin layer of wool. 
If the trouble is only local — a frozen ear or foot — begin by rubbing 
the part with snow or ice and then with cold water and finally apply 
cold compresses, gradually raising their temperature until the circu- 
lation is restored. Subsequently cooling lotions may be employed 
to allay the inflammation. 



PART II. 



CHAPTER I. 



TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. 



Tracheotomy is often performed in general practice as an operation 
of tlie greatest urgency, and one should be prepared to do it anywhere, 
at any time, and if necessary, with a pen-knife. Yet it is not so simple 
a procedure as one might infer. To do it properly and quickly, 
requires coolness, knowledge and method. It is 
the measure of relief indicated in every case of 
laryngeal asphyxia, whether due to spasm of the 
larynx, edema following burns, injuries, or disease 
such as diphtheria or cancer; or to the presence 
of foreign bodies. The essential equipment is a 
sharp pointed scalpel and a tracheotomy tube, 
and to these as mere conveniences, may be added 
scissors, artery and dissecting forceps, tenacula, 
mouth-gag, and tongue forceps. 

The tracheotomy tube (Fig. 282) should be of 

simple construction, easy to introduce and as 

large as the diameter of the trachea will admit. Treves furnishes the 

following table relative to the age of the patient and the diameter of 

the tube: 




Fig 



-Tracheotomy 
tube. 



AGE. 

Under 18 months, 

1 1 to 2 years, 
2 to 4 years, 
4 to^8 years, 
8 to 12 years, 

12 to 15 years, 
Adults, 



DIAMETER OF THE TUBE. 



372 



4 


mm. 


5 


mm. . 


6 


mm. 


8 


mm. 


10 mm. 


12 


mm. 


i2*to 15 mm 



OPERATION FOR TRACHEOTOMY. 



373 



Every practitioner should have tubes of various sizes in his "ar- 
senal;" Senn recommends Trosseau's, while Lejars prefers those of 
Krishaber. 

Anesthesia is often unnecessary, owing to the condition of the 
patient. Otherwise a few whiffs of chloroform should suffice. It 
need scarcely be said that under these circumstances, free use of the 
anesthetic will only hasten the fatality. 

The preparation of the field, however desirable, the urgency of the 
symptoms will scarcely permit. 




Fig. 283. — Locating the cricoid cartilage. (Veau.) 



The little patient's arms should be pinioned to its sides with a 
towel or sheet, it should be placed on its back with a cushion under 
its shoulders to drop the head backward and bring the trachea into 
bolder relief. 

Operation. — Stand at the right side of the patient; locate the hyoid 
bone, the thyroid prominence, the cricoid cartilage, and the sternal 
notch; and steady the trachea, holding the cricoid between the middle 
finger and the thumb of the left hand while the index finger locates 
the middle line (Fig. 283). 

It is along the middle line that one must incise, and the aim is to 



374 



TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. 



divide the upper rings of the trachea and to avoid the thyroid isthmus 
(Fig. 284). 

Make the incision from the index finger downv^ard exactly in the 
middle line for two inches (Fig. 285). Incise rapidly with a single 
sweep of the knife. The left index finger in the upper angle of the 
wound hooks up the cricoid and still locates the middle line. Pay 
no attention to the bleeding, and without hesitation push the point 
of the bistoury through the upper ring and cut downward through the 
second and third if necessary. The air hisses through the opening. 
It is a moment of confusion, but one must keep cool. 

Insert the tube. Without changing its position, 
the left index finger presses the tracheal wound 
open and the right hand introduces the tube, 
horizontally at first until the point is well in the 
trachea, and then carries the tube upward in a 
curve until its beak corresponds to the lumen of 
the trachea (Fig. 286). The patient's gasps expel 
blood and perhaps false membrane, which the 
attendants must avoid inhaling. The tapes at- 
tached to the tube are fastened behind the neck. 
Apply artificial respiration if the patient's condi- 
tion is not satisfactory. Let the air pass through 
a warm, moist compress until the temperature of 
the room can be regulated. 

As Veau points out, the operation may fail for 
several reasons, all within the control of the operator. The most 
frequent cause of failure is faulty introduction of the tube; it does not 
enter the tracheal canal but is pushed down between the mucous 
membrane and the tracheal wall. These structures are loosely 
connected. The error is to be recognized by the absence of the 
characteristic sound of escaping air. 

The orifice is to be inspected, and if too small, enlarged before trying 
the second time to introduce the tube. 

Again too much force in making the incision may result in wounding 
the posterior wall of the trachea. Excited operators have split the 
trachea its entire length, or wounded the vessels of the neck. There 




Fig, 284. — Tracheo- 
tomy. Dotted lines 
represent the thyroid 
isthmus. (Veau.) 



OPERATION FOR TRACHEOTOMY. 



375 




Fig. 285. — Tracheotomy. Incision. (Veau.) 




Fig. 286. — Introducing the tracheotomy tube. (Veau.) 



376 TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. 

need be but little hemorrhage in the operation if one but keeps in the 
middle line, and as Senn says, that is the secret of success in performing 
the operation quickly and safely. 

The operation may be varied somewhat, depending, of course, upon 
the conditions. The cricoid may be divided if necessary. In other 
cases, before cutting downward it may be necessary to draw downward 
the isthmus of the thyroid gland before enlarging the opening. 

In any case wdiere time does not press, as when the tracheotomy is 
done preliminary to some other operation, the various steps may be 
carried out with more detail, the incision made by layers, vessels 
clamped, and the rings exposed, steadied with hooks and incised. 

The tracheotomy may be done below the isthmus of the thyroid, 
but the higher operation is much the easier anatomically although the 
principle is the same. 

Ajter-treatment. — As Senn says, the success of tracheotomy rests 
largely on the care with which the after-treatment is conducted. 
There is no operation perhaps, in which care and skill are better 
rewarded and negligence and ignorance more severely punished. 
If the temperature of the room cannot be kept at close to 65°, the tube 
should be kept covered with a warm, moist compress. The wound 
must be kept clean. For the first few days, the inner tube must be 
removed and cleansed several times daily. This should be done 
rapidly, and the tube disinfected and oiled before being reintroduced. 

Morse (Post-operative Treatment, page 174) says unless the cause 
of obstruction is a permanent one, it is often advisable to remove the 
tube after twenty-four to forty-eight hours, but the patient should be 
allowed to try breathing through the mouth before removing the tube, 
testing his capacity by stopping the canula. In any event, he should 
be gradually accustomed to breathing through the mouth by plugging 
the canula. 

Morse advised that soup, milk or broth should be given at first, 
if necessary through a nasal or esophageal tube, although this is not 
often required. Difficulty in swallowing is likely to occur on the third 
or fourth day, but encouragement will enable the patient to overcome 
this. Nutrient enemas are rarely necessary. 

Link, of Indianapolis, relates an experience (Medical Record, 



OPERATION FOR TRACHEOTOMY. 377 

March 2, 1907) which illustrates at once the value of the operation, 
tlie improvization of instruments to meet an emergency, and one of 
the rarer forms of suffocating edema. 

At midnight he was called to see a patient said to be choking to 
death and whom he supposed had an attack of asthma. He found 
the patient, a man weighing 250 pounds, cyanosed and laboring for 
breath. One hour previously, it seems, his throat had been lanced 
for the eleventh time in the course of a ten days' attack of tonsillitis. 

A hurried examination found the pharynx too tightly swollen to 
pass a finger. How much laryngeal edema there might be could 
only be guessed. Thinking to intubate past the swollen pharynx, 
Link used the only thing available, the vaginal tip from a hard rubber 
syringe, bent at nearly a right angle. The attempt failed. While 
preparing for a local anesthesia to do a tracheotomy, the patient's 
neck was surrounded with iced cloths but this seemed to aggravate 
the asphyxia; the patient became unconscious and ceased to breathe. 

The anesthesia was no longer necessary. All had fled but one 
woman, and while she held the patient's head, the doctor did a low 
tracheotomy. 

He says, kneeling in front of the patient, who was in a sitting posture, 
he incised the skin and deep fascia' in the median line two inches 
above the sternal notch, working with his finger down to the bron- 
chial rings. With the finger as a guide, the knife was introduced, 
the trachea stabbed and cut slightly upward. A closed hemostat 
was then introduced and opened. Very little blood was lost. A 
female silver catheter from his pocket case was introduced and held in 
place by the assistant, while the doctor performed artificial respiration. 

The patient soon began to breathe but his convulsive movements 
threatened the loss of the small tube in the throat. The hard-rubber 
vaginal syringe tip was brought into use again, whittled and inserted. 
The elbow shape fitted perfectly. In half an hour the patient asked 
to be put to bed, and breathing entirely through the tube,, slept the 
first sleep for several nights. 

The edema declined as fast as it had arisen, and, within a few hours, 
the patient could breathe through the mouth when the tube was 
closed, and recovery was uneventful. 



378 



TRACHEOTONY, LARYNGOTOMY, ESOPHAGOTOMY. 



LARYNGOTOMY. 

As an emergency operation, this is most frequently done in an- 
adult for cancer, but one need not wait until the patient is asphyxiated 
for there is nothing gained thereby. Therefore one may operate 
deliberately, for there is not the extreme urgency as with the infant. 

Local anesthesia may be sufficient. Define as before the inferior 
border of the thyroid cartilage and the upper border of the cricoid, 
between which is the crico-thyroid membrane 
which is to be incised (Fig. 287). In the 
middle line over the space, make a vertical 
incision an inch long. Catch the bleeding 
points and retract the lips of the wound. 
Carefully incise the fascia until these cartilages 
are exposed. Now incise the crico-thyroid 
membrane transversely and open into the 
larynx (Fig. 288). 

Introduce the tube as in tracheotomy. Re- 
move and cleanse the inner tube on the first 
two days and the large tube on the third day. 

Of cour.se if the operation is for cancer, it is 
merely palliative and the patient will continue 
slowly to die. If the operation is for edema of the larynx, the cause 
must be treated and the proper time finally to withdraw the tube 
determined by the conditions. If the operation is for a foreign body, 
the wound may be sutured at once. 




Fig. 287. — Laryngotomy. 
Incision of crico-thyroid 
membrane. (Veau.) 



ESOPHAGOTOMY (Cervical Region). 

Position. — Place the patient on his back with shoulders elevated 
and the neck resting on a sand bag with head turned to the right. 

Incision. — Begin opposite the upper border of the thyroid cartilage 
and continue downward along the anterior border of the left sterno- 
mastoid for three or four inches, incising the skin, superficial fascia 
and platysma. Ligate the veins and draw the sterno-mastoid forward 
and the depressors of the hyoid downward. The wound is thus 
enlarged and at the bottom is the layer of cervical fascia connecting 



OPERATION FOR ESOPHAGOTOMY. 



379 



the thyroid gland and the sheath of the large vessels. Incise it and 
again enlarge the wound by drawing forward the thyroid gland, 
trachea and larynx, and backward, the great vessels in their sheaths. 

At this stage, in the bottom of the wound are the inferior thyroid, 
which must be ligated, and the recurrent laryngeal nerve, which 
should be drawn forward. 

The esophagus now appears as a red tube. To steady the esoph- 
agus and define its walls, an esophageal bougie may be inserted. The 




Fig. 288. — Laryngotomy. Incision of the crico-thyroid membrane. (Veau.) 



wall of the esophagus is raised with mouse-tooth forceps (Fig. 289) 
and incised along its lateral wall. A suture is passed through each 
lip of the incision, that they may be readily retracted while the foreign 
body is located and removed, not always the easiest part of the task. 

The wound of the esophagus is repaired with sutures of catgut 
and the rest of the wound lightly packed with gauze until all danger 
of infection is passed. 

As Bryant says, ordinarily the operation of cervical esophagotomy 
is not a perplexing procedure, but when-the neck is short and fat, the 



38o 



TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY. 



vessels and thyroid gland enlarged, the detection and removal of the 
foreign body difficult, or the patient exhausted, the operation often 
taxes the patience and fortitude of the surgeon. 

After-treatment. — The patient must be kept in bed with shoulders 
raised. Nourishment should be given at first 
by enemata, and later, if necessary, by the 
esophageal tube. 

Nassau reports a case illustrating the subject 
(Annals of Surgery, Feb., 1908). A child 
swallowed a five-cent piece and thereafter could 
take only liquid foods. "X" ray examination 
showed the coin lodged at the level of the 
suprasternal notch or just above. 

Removal was attempted with forceps but 
without success, although the coin could be felt. 
An esophagotomy was done. The operation 
was completed in fourteen minutes. No vessels 
required ligation. The esophagus was not sutured and the superficial 
wound was closed with drainage. There was no leakage and the child 
made an uneventful recovery. Nassau does not regard esophagotomy 
as a serious operation but believes it should not be considered until 
efforts of extraction have failed. 




Fig. 289. — Esophagot- 
omy. Final incision. 

(Bryant.) 



CHAPTER II. 

URGENT THORACOTOMY. REPAIR OF INJURY TO THE 

LUNGS. REPAIR OF INJURY TO THE PERICARDIUM ; 

OF INJURY TO THE HEART. PUNCTURE OF THE 

PERICARDIUM. 

z\s has been indicated elsewhere (see injuries of the thorax) urgent 
intervention for injuries of the thorax is a form of operative procedure 
at this present time with but a limited field. Whatever may be the 
apparent gravity of the case, it is far from being the rule to operate, 
for such operations require trained assistants, a special equipment, and 
a superior surgical skill. Of necessity, then, in general practice, the 
treatment must, generally speaking, be conservative: that is to say, 
cleansing of the external wound with enlargement and trimming up 
if necessary, reunion and aseptic occlusion, firm bandaging of the 
thorax and an absolute quiet in bed. These measures along wdth 
stimulation with caffein and camphorated oil and normal salt solution, 
represent the elements of treatment which are within the scope of all. 

But there are cases so manifestly fatal without operation that, as 
Lejars says, one cannot evade the question, "operate or let die?" 

Grave rupture of the lung indicated by an immediate flooding of the 
pleural cavity, followed by urgent symptoms of asphyxia and syncope, 
is the signal for immediate operation. Again, repeated attacks of 
secondary hemorrliage call for operation. 

Urgent Thoracotomy. — The technique of this operation can be exactly 
defined only in a general way and will need to be modified to suit the 
individual case. 

Lejars insists that the opening must be large, that anything less will 
be a disappointment and the operation might as well not be undertaken. 

The operation may proceed in one of two ways; (i) by a permanent 
resection of the ribs necessary to be removed, or (2) by temporary 
resection with the formation of a thoracic flap. 

381 



382 URGENT THORACOTOMY. 

(i) Make a U-shaped incision forming a flap with its base posterior, 
and of which the two arms run parallel with the ribs and are wide 
enough apart to include at least three ribs. 

The incision reaches to the ribs. Rapidly dissect up this muscu- 
lo-cutaneous flap, exposing the ribs and intercostal muscles. With 
the flap held out of the way begin the resection of the ribs by incising 
the periosteum of the lowest rib along its middle line, the full length 
of the exposed part. Denude the rib wath the rugine. Take special 
care in the denudation along the lower border that the artery and nerve 
removed with the periosteum are not wounded. Divide the inner 
and the outer end of the denuded segment. (See operation for em- 
pyema.) Resect the other ribs exposed in the same manner. 

Raise the Musculo-pleural Flap. Begin by dividing the upper border; 
then the lower border; and finally the anterior border, catching each 
intercostal artery as cut. When this flap is lifted the lung is exposed. 

This procedure has the advantage that it can be rapidly carried out; 
the disadvantage that it permanently sacrifices a part of the bony 
wall of the chest, but that is a small matter in the face of such emer- 
gencies. 

(2) A thoracic flap may be formed. Make the same "U"- 
shaped incision and expose the ribs as in the preceding operation. 
Each costal segment is then denuded of periosteum at either end sufi&ci- 
ently for the passage of the bone-cutting forceps. In this manner 
each rib is divided at each end. 

Next carefully divide the intercostal muscle parallel with and above 
the first segment and lift the anterior end of this rib, and begin the 
separation of the pleura. 

Work along the front at first, dividing the intercostal muscles and 
arteries and ligating as necessary. The liberation of the flap along 
the low^er border next follows and as the musculo-osseous flap is more 
elevated the separation of the pleura is more and more facilitated. 

Finally the flap is freed and turned back and the pleura is left bared. 
The pleura is next divided and the wounded lung is now freely exposed. 

Wipe out the clots and search for the bleeding surface. If necessary 
a hand may be slipped under the base of the lung pulling it forward 
for inspection. 



TREATMENT OF INJURIES TO THE HEART. ^8;^ 

Repair the Lung. The ideal method is by suture, employing a No. 
I or 2 silk thread and passing it through the parenchyma with a round 
curved needle. If this is not possible tamponade is the next resort. 
If a border is lacerated and projecting it may be ligated en masse and 
resected. 

Whether or not drainage is employed depends upon the amount 
of oozing and the probabilities of infection. If infection subsequently 
develops the infected area is to be opened and drained as any other 
empyema. 

REPAIR OF INJURIES TO PERICARDIUM AND HEART. 

The general practitioner does not see many injuries to the heart. 
Gunshot wounds are of course usually immediately fatal, so that the 
form of cardiac injury most likely to present itself for treatment is a 
stab wound. Occasionally the heart is lacerated by a broken rib. 
The sudden death from cardiac wounds may occur in several ways. 
It may occur from syncope arising from the pressure of the blood 
within the pericardium; or the heart may- be unable to contract be- 
cause of its divided fibers and cerebral anemia follows; or shock or 
pulmonary edema may be the immediate cause of death. 

Even if death does not immediately occur, hemorrhage and infection 
may later provoke a fatal issue. (See injuries to the thorax.) 

The treatment of traumatisms of the heart and pericardium has 
three ends in view; to combat shock, to control hemorrhage, and to 
prevent infection. 

Keep the patient absolutely quiet, lower the head, apply artificial 
heat, give morphine in small doses (J gr.) hypodermically, and 
if there is an open wound in the chest, disinfect and dress asepti- 
cally but do not operate merely to disinfect. 

If the heart is injured sufficiently to bleed, operate. The sole in- 
dication then for operative treatment is hemorrhage. 

The patient will probably die even if operated upon, but he will 
most certainly die without the operation, so that it is our duty to give 
him the additional chance by intervening. 

If the wound seems likely to have reached the heart; if there is 



sH 



URGENT THORACOTOMY. 



bleeding; if there is pain and precordial oppression; if there are fre- 
quent attacks of syncope; if there are signs of increase of fluids about 
the heart; then one is justified in believing that the heart has been 
wounded sufficiently to produce hemorrhage and must prepare im- 
mediately for the operation. There must be no delay. It will depend 




Fig. 29c. — Forming the costal flap. The three ribs in the flap are divided near 
the sternum, and the upper and lower libs divided at the outer limit of the flap. 
The middle rib to be fractured by raising the flap. 

upon the degree of urgency whether the time shall be taken for 
thorough aseptic preparation of the field. However indispensable 
asepsis may be, yet hemostasis in such cases is the more urgent 
indication. The doctor must decide for himself whether the indication 
is for operation with or without preparation. In the most desperate 



OPERATION FOR REPAIR OF THE HEART. 



385 



cases he must at least scrub his hands and wash the field, for there 
is little use to check the hemorrhage if the patient is to die later from 
sepsis. 

General anesthesia. Ether should be employed if the patient's con- 
dition will permit. 




Fig. 291. — Costal flap reflected. Pleura retracted. Edges of pericardial wound 
held in forceps and heart wound exposed. 



The operation proposes to make a thoracic flap, to open the peri- 
cardium and expose the heart, and to repair the injury. There is 
no operation that requires more decision, courage and self-control. 

Incision. — Begin in the third intercostal space just in front of the 
anterior axillary border and cut inward to the border of the sternum, 
abruptly curving there and following the sternal border downward 
25 



386 URGENT THORACOTOMY. 

to the sixth space; again abruptly curving and following that space 
outward (Fig. 290). These incisions expose the ribs and intercostal 
muscles. 

Formation oj the Flap. — Divide the fourth, fifth and sixth cartilages 




Fig. 292. — Heart supported in palm of hand preparatory to suturing. (After Lejars.) 

near the sternum and also the intercostal muscles, along the line of the 
original incision. 

At the lower outer angle of the incision expose the sixth rib by- 
pulling the tissues upward. Incise the periosteum over its external 
surface and with the rugine free the rib of periosteum and divide it. 



SUTURE OF WOUND OF THE HEART. 



387 



At the upper outer angle expose the fourth rib, free it of periosteum 
and with the costotome or a bone cutting forceps divide it in the 
same way. The flap is now attached only by the fifth rib which is to 
be fractured. Raise the sternal end of the flap with the left hand and 
press on the fifth rib with the right hand and with a little force the rib 
is broken in the line of section of the other two ribs. 

The flap is now gradually raised as its adhesion to the subjacent 
structures are freed, and the pleura is exposed. 

If there is a wound in the pleura, it may be enlarged and the pericar- 
dium may be reached through it; otherwise proceed to the liberation 
and retraction oj the pleura. With a grooved director liberate the 





sr.H. 



Fig. 293. — Suture of wound of heart. 



Fig. 294. — Suture of heart completed. 



fibrous attachments of the triangularis sterni to the posterior surface 
of the sternum, which at the same time liberates the pleura. With 
the fingers, draw outward the free border of the pleura with its covering, 
the triangularis sterni (Fig. 292). In this manner is the pericardium 
exposed. The assistant holds the pleura with a retractor. 

Incision oj the Pericardium. — Enlarge the wound in the pericardium 
and in that manner expose the heart. Retract the edges of the peri- 
cardial wound with forceps. Locate the wound in the heart. Slip 
the left hand under the apex and pass the first suture and the heart 
may be thereafter steadied by traction on the threads of the first suture. 

Suture the wound in the heart. Use either interrupted or continuous 



388 URGENT THORACOTOMY. 

suture of catgut. There is no particular advantage in passing the 
suture in diastole. Pass them deeply but not to the" endocardium. 
(Figs. 293, 294). 

Now wipe out the pericardium with sterile compresses and repair 
the pericardium by continuous catgut suture. Next wipe out the 
adjacent portion of the pleural cavity, repair any part of the lung 
that may be injured and repair the pleura without drainage. Finally 
replace the thoracic flaps and suture. 

No drainage is to be employed except under these circumstances: 
if the case was operated on late and there is great probability of 
infection it is better to leave drainage in the pleural wound, pro- 
jecting from the thorax at the lower angle of the skin wound; if there 
is much oozing it is better to leave a wick of gauze in the pleural wound. 

A case of successful suture by Gibbon, of Jefferson Medical College, 
illustrates the subject (Jour. American Medical Assn., Feb. 10, 1906). 
Patient, aged 38, healthy colored man. Stab wound of chest, a few 
moments after which he fell unconscious. An hour later at the hos- 
pital his condition was very grave: unconscious, cyanosed, pupils 
dilated, skin cold and moist, respiration rapid and shallow. No pulse 
in the peripheral vessels and the heart sounds were distant, rapid and 
irregular. 

Vigorous stimulation was employed with morphia and atropia, 
and his condition slightly improved. Operation about one and one- 
half hours after the injury. Only a small quantity of ether required. 

The fourth costal cartilage was found and divided and the entire 
cartilage and a part of the rib was removed. The pericardium 
was explored and a wound located which would only admit tip of 
index finger. This pericardial wound was enlarged and the sac 
emptied of clots and liquid blood. It began rapidly to fill again. 
Two fingers passed under the heart lifted it up into the pericardial 
opening and with rapid sponging, the wound was located. It was 
situated in the right ventricle near the auriculo-ventricular groove. 
It bled freely, controlled by pressure; was about three-fourths inch 
in length. The wound in the endocardium w^as about one-half as 
long. 

A traction suture of chromicized catgut was passed through both 



REPAIR OF WOUND OF THE HEART. 389 

edges and by that means the heart was held in position, while four 
other sutures were passed and no effort was made to avoid the en- 
docardium. A small gauze drainage was applied to the line of 
sutures and brought out through the pericardial wound which was 
not sutured. 

During the subsequent twelve hours there was enough oozing 
to require a change of dressing. His general condition was fairly 
good. The second day his condition was alarming; respirations 62. 
The gauze was found to be interfering with drainage and removed. 
The respirations fell to 38 in a short time. 

Large quantities of salt solution were given by rectum. Liquid 
food on second day. The dressings were changed every other day. 
Six days after the operation the skin wound was sutured almost com- 
pletely, the w^ound in the pericardium being practically healed. 
In six weeks he returned to work completely recovered with heart's 
action regular and normal. 

Gibbon does not advise an osteo-plastic flap unless a pleural wound 
is demonstrated, believing it best to excise as much of the sternum 
or cartilage or rib as may be necessary to give free access. He em- 
phasizes the value of the traction suture, and advises the repair of 
the pericardial wound without drainage, but would always drain the 
external wound. 

Travers (Lancet, Sept., 1906) operated upon a case in which the 
patient was impaled upon a spike fence. The right ventricle was 
torn, the spike penetrating the sternum to reach it. The wound 
in the heart was closed by twenty sutures. The patient did very well 
up to the eleventh day, when he died from heart failure, due to the 
pressure of a slowly forming clot. 

Travers notes that the suturing seemed to stimulate the flagging 
heart. 

Stewart, who first in the United States successfully sutured the heart, 
turned the musculo-cutaneous flap to the left and the thoracic flap to 
the right, fracturing the cartilages near the base of the sternum. 

The pericardial wound was enlarged in the axis of the heart. The 
heart wound, produced by a stab with a long, rusty pen-knife, involved 
the thickness of the left anterior ventricular wall, ran parallel with the 



Sgo URGENT THORACOTOMY. 

axis of the heart, and was about three-fourths of an inch in length, was 
larger than either the skin, pleural or pericardial w^ound. The heart 
bled freely and continuously, and resembled a mere quivering mass 
of muscle. 

The wound was closed with a continuous silk suture, the pericardial 
cavity cleansed, and the sac sutured wdth silk. A gauze drain was 
left at the lower angle. The pleural cavity was cleansed and irri- 
gated with salt solution. The thoracic flaps were sutured with silk- 
worm gut and a gauze drain left also in the pleural cavity. 

During the operation, which lasted about forty-five minutes, twenty- 
four ounces of salt solution and adrenalin were injected, and strychnin 
and atropia given hypodermically. 

Some infection followed, and by the eighth day, the temperature 
was 103°, pulse 150, and respiration 50. From that time, the symptoms 
of sepsis gradually declined until at the end of three weeks, these con- 
ditions were practically normal; at the end of the fifth week, the patient 
was out of bed. 

Stewart, discussing the operation (American Journal Med. Sciences, 
Sept., 1904) notes that the size of the heart w^ound can not be predicated 
from the external wound, and concludes that the only safe procedure 
in doubtful cases is to enlarge the wound and ascertain if it penetrates 
the chest wall, and if there be symptoms of hemorrhage — of heart 
tamponade — operate. 

PUNCTURE OF THE PERICARDIUM. 

Puncture of the pericardium — paracentesis pericardii — is indicated 
in those cases of hemo-pericardium and serous effusion in which 
the accumulating fluids dangerously interfere with the functions of 
the heart. The physical signs and the symptoms point to the nature 
of the difficulty. It is not more frequently done because of the in- 
stinctive fear that one may wound the heart; indeed there are three 
structures which may be wounded with serious consequences, the heart, 
the pleura, and the internal mammary artery. 

The puncture may be made near the sternum to the inside of the 
internal mammary; it may be made to the outside of the internal 



PUNCTURE OF THE PERICARDIUM. 39 1 

mammary, between it and the line of the pleura. The latter is per- 
haps the better. 

The point of entrance of the needle is in the fifth left intercostal space, 
6 cm. from the sternal border. Use a small trocar or an aspirator. 
Cleanse the field thoroughly. Put the patient in a half reclining posi- 
tion on his bed and mark with the left index finger the site of the 
puncture. 

Direct the needle obliquely downward and inward and do not 
penetrate deeper than 2.5 cm., holding the needle so as to regulate 
that. 

As the pericardium empties itself, gradually elevate the trocar so 
as not to wound the heart. 



CHAPTER III. 
EMPYEMA— PURULENT PLEURISY. 

Various bacteria may attack the pleura, most frequently they are 
the pneumococcus, the streptococcus, the staphylococcus, the bacillus 
tuberculosis or the bacillus communi coli. 

The pneumococcus is usually present in the empyema of childhood. 
Be on your guard for empyema, especially in whooping cough. 

The clinical history and the prognosis vary in different forms of 
the disease and are directly dependent upon the form of the infection. 

But, whatever the pyogenic agent, when pus has once formed in the 
pleural cavity, it seeks for an outlet in various directions. It may 
rupture into a bronchus and escape by the mouth, and, under these 
circumstances, pneumothorax may ensue; it may perforate the chest 
wall, manifesting itself as an external abscess of various forms; it may 
open into the pericardium, esophagus, or stomach. 

In every case, the longer relief is delayed, the greater the probability 
that the lung will be permanently collapsed or bound down by ad- 
hesions. Finally, in some degree, there are always the evil results of 
sepsis. There is every reason, then, when pus is known to exist in the 
pleural cavity, to drain without delay. 

The diagnosis rests upon the history of the case (remembering that 
this history will vary with the form of infection), upon the pain, the 
constitutional symptoms which are those of sepsis generally, and upon 
the physical signs. These are: distention of the thorax accompanied 
perhaps by edema of the chest wall; flatness on percussion and evident 
displacement of neighboring organs ; absence of the vesicular murmur, 
and the presence of bronchial breathing. 

Taylor, of Springfield (Illinois Med. Jour., 1907), attributes the 
most frequent source of error in diagnosis to a misconception of the 
position assumed by the exudate. 

Physicians are observed trying to establish a horizontal line for 

392 



EXPLORATORY PUNCTURE OF THE PLEURA. 



393 



the exudate with the patient in the sitting posture under the impression 
that the fluid will follow the influence of gravity. But this is the 
exception rather than the rule. The dullness is usually higher pos- 
teriorly. The "S" shaped line of Ellis, if present at all, is so variable 
from day to day as to be of minor importance. Taylor remarks 
further that the character of the fluid is often a matter of doubt. 
Chills and variable temperature point to pus, although he has seen 




A. 

V . 



i 




.^^■., 



Fig. 295. — Puncture of the pleura. (Lejars.) 



patients recovering from pneumonia who had none of these symptoms 
and yet carried around three pints of pus in the pleural cavity. 

Most of the signs and symptoms may occur as well with pleurisy 
with effusion, and it is only by exploratory puncture that the matter 
may be definitely determined (Fig. 295). 

Exploratory puncture, then, is the court of final resort and must 
always be employed before deciding upon the form of treatment. 



394 EMPYEMA PURULENT PLEURISY. 

As has been said, every purulent pleurisy must be opened as soon 
as possible, must be opened freely and at its lower point. 

In the case of a child, it suffices usually to incise the intercostal 
space in order to perfect a cure. In the case of the adult, it is nec- 
essary to resect a rib for adequate drainage and even then the patient 
may shortly die or retain a chronic sinus. .These possibilities should 
always be explained before the operation, necessary but disagreeable, 
is undertaken. As a rule it is advisable, we will say, to resect a rib, 
although in the recent case, uncomplicated, ob- 
viously benign, a good result may be obtained by 
simple incision. Carstens, of Detroit, has re- 
cently said he thinks we resect far too many ribs 
in these conditions. 

Site of the Incision. — The cavity must be opened 
where it will drain best in the recumbent position. 
The lowest level of the abscess can be determined 
only by exploratory puncture; any other method 
is useless. Having already confirmed the diag- 
FiG. 296.— Empyema: Hosis by puucturc, uow at the beginning of the 
cavfty°to the chest wall Operation, make another exploratory puncture in 
and lung. (Veau.) ^^^ space next lowcr. If pus is found there, 

puncture again in the space below and so on, until no pus is found. 
The last puncture producing pus, will be the site of the incision. 

Anatomy (Fig. 296). — The aim will be to incise parallel with the rib. 
In going through the structures of the intercostal space, remember 
that the vessels and nerve lie in or near the groove in the lower border 
of the rib. Incising any space, therefore, keep close to the lower 
line of the space, keep near the upper border of the rib forming the 
lower boundary of the space. If a rib is to be resected, it should be 
denuded of its periosteum, which is loosely attached and on that 
account, easily stripped off. 

EMPYEMA IN THE CASE OF A CHILD. 

In the case of a child, simple incision of the pleura will sufl&ce. 
Under general anesthesia, if the condition of the patient will permit, 
make an incision three or four inches long, parallel with the ribs. 




OPERATION FOR EMPYEMA. 395 

The incision traverses the skin, and beneath it a cellular layer, often 
edematous. Next divide the muscles, letting the rib serve as a re- 
sisting plane. In front they are thin (pectoralis major); behind, 
thicker (latissmus dorsi and serratus magnus). Divide them at a 
single stroke and without concern. A small artery may need to be 
clamped. 

Having exposed the rib (Fig. 297) retract the upper lip of the wound 
and locate the upper border of the rib; below it bounds the space 




Fig. 297. — Incision of the pleura without resection of a rib. (Schwartz.) 

about to be penetrated. Following this border, incise layer by layer 
the intercostal muscles. There is never any serious hemorrhage. 
As you approach the pleura, be prepared for a sudden spurt of pus, 
and when the pus flows, it is evident the pleura is opened. Enlarge 
the opening, using the left index finger as a guide. Incline the patient 
so that the cavity may be entirely emptied. Fix the drainage tube 
(see further). 

EMPYEMA IN THE CASE OF AN ADULT. 

In the case of empyema in an adult, it is usually necessary to resect 
a rib. One needs a bone cutting forceps or a costotome and a curved 
periosteal elevator or rugine in addition to the ordinary instruments. 

Local Anesthesia. — It is a grave error to give chloroform for it is more 
than likely to hasten the patient's death. It is rare in such a case 
that any form of general anesthesia is safe, still it maybe necessary 
with the excessively timorous. 

Having determined the site of incision by exploratory puncture, 
incise the skin and muscles as in the case of a child. The length of 



396 EMPYEMA PURULENT PLEURISY. 

the incision will equal four fingers' breadth. When the rib is exposed, 
divide its periosteum in the middle line (Fig. 298). 

The denudation oj the rib is an important step. With the rugine or 
curved periosteal elevator, uncover the upper half of the external 




Fig. 298. — Incision of the costal periosteum. (Veau.) 

surface of the rib first and then the lower half, keeping very close to 
the rib as you reach the lower border, so as not to wound the intercostal 
vessels or nerve, which are closely attached to the periosteum and are 
removed with it. Finally uncover the deep surface of the rib. Care- 



FiG, 299. — Uncovering the posterior surface of the rib with rugine. (Schwartz.) 

fully slip the elevator upward between the bone and its periosteum, 
which is loosely attached (Fig. 299). Carry the elevator to one end of 
the section and then to the other and the part of the rib to be removed 
is thus entirely freed from its periosteal attachment. 



OPERATION FOR EMPYEMA. 397 

Divide the rib. Introduce one blade of a bone forceps or costotome 
under one end of the section to be removed and divide it (Fig. 300). 
Then divide the other end (Fig. 301). The bone removed should be 
two and one-half to three inches long. The stumps should not 




Fig. 300. — Section of the rib. (Schwartz.) 

project beyond the limit of the flesh wound, else necrosis is favored. 
Incise the pleura. With the rib removed, the periosteum remains 
attached to the pleura and this periosteal layer is incised along its 
middle (Fig. 302), and the pleura is divided at the same time. Be 
on your guard, when making the incision, for a spurt of pus. 




Fig. 301. — Section of the rib. (Schwartz.) 



Empty and drain the cavity. Incline the patient to one side and 
instruct him to cough. The pus pours out, often oft'ensively fetid. 
Take plenty of time. Finally wipe out the cavity with sterile gauze. 
Irrigation is usually inadvisable; but if used, employ only warm, 



398 



EMPYEMA ^PURULENT PLEURISY. 



sterile water, salt solution, or a weak solution of peroxide. The 
stronger antiseptics are dangerous. Do not suture the wound except 
to cover over the projecting end of the divided rib. The difficulty 
is to keep the wound open. 

Drainage must never be neglected. Employ two large and long 




Fig. 



-Rib removed, pleura incised. (Veau.) 



tubes placed in different directions and anchor with safety pins (Fig. 
303), or by a suture, else they may be lost in the abscess cavity. 

Dressing. — This is important. Pack moist sterile or boracic 
gauze all around the tubes, between the lips of the wound. Apply 
an ample dressing of absorbent ootton, which covers half the thorax, 
and hold all in place with a large flannel bandage maintained by 




Fig. 303. — Drainage of the pleural cavity. (Veau.) 

suspenders. Let the patient occupy the half sitting position, in- 
clined toward the affected side and supported by pillows at the back. 
Subsequent Care. — After a few hours change the dressing, which is 
usually saturated, but do not disturb the drains. Change the dressing 
twice daily until the discharge diminishes and about the third day 



DRAINAGE FOR EMPYEMA. 399 

withdraw, cleanse, and replace the tubes in the safne place and to the 
same depth, else look for trouble if you fail to accomplish this. 

Do not irrigate while making these dressings unless the discharge 
has persisted undiminished for a week and continues fetid, when it is 
best to use a sterile wash of salt solution or dilute peroxide, which 
is to be injected under very slight pressure. 

The end results vary with the nature of the infection. 

(i) The meta-pneumonic pleurisy of children is usually cured. 
About the fifteenth day, smaller tubes may be used and are gradually 
to be shortened as granulation proceeds. In the fortunate case, the 
opening will- close in something like two months. 

(2) In tubercular pleurisy with secondary infection, cure scarcely 
ever takes place. The patient will probably die in a few months of 
amyloid degeneration. Even if the patient does not die soon, the 
suppuration shows little tendency to yield. Of course the purely 
tubercular pleurisy must be treated by puncture. 

(3) Streptococcic or staphylococcic pleurisy: The patient may 
go on to death or else recovers with persistent sinus. Keep the orifice 
open for if the pus is allowed to accumulate, it will be necessary to 
operate again. Keep watch on the functions of the kidney and liver. 
Remember the frequency of metastatic abscess, as of the brain, for 
example. 

After two to four months, the case may be referred to a specialist 
for a plastic operation. 



CHAPTER IV. 
URGENT CRANIECTOMY: TREPHINING. 

FRACTURE OF THE SKULL. 

There are two conditions which may accompany fracture of the 
skull, singly or together, either of which demands immediate relief. 
(See fracture of the skull.) 

(A) The depressed fragments have contused and lacerated the 
brain: consciousness was immediately lost and was not regained. 
Under these circumstances, the fragments must be elevated without 
delay. 

(B) Hemorrhage has occurred within the cranial cavity and the 
clot compresses the brain. In this case, there is a "free interval." 
The patient regains consciousness and perhaps for a time — two to 
twenty-four hours — appears not to be seriously injured, but little by 
little the signs of "compression" develop, namely: restlessness, dull- 
ness, stupor, coma; normal pulse at first but which finally grows slow, 
full and bounding; and slow and stertorous breathing. Delay is 
dangerous. The clot must be removed and the hemorrhage checked. 

Nearly always it is the middle meningeal which is at fault. There 
is in consequence an extradural hematoma. Once in a while, howevei, 
the bleeding will be found to proceed from a ruptured sinus or from 
the pial arteries and there exists at the same time an injury to the 
brain substance. There is in this case, an intradural or intracerebral 
hematoma. 

Whatever the form of compression, one is compelled to operate, 
but he must first get the anatomy of the middle meningeal artery 
clearly in mind. 

The middle meningeal, a branch of the internal maxillary, is the size of 
the radial, entering the cranial cavity at the base of the skull, through the 
foramen spinosum. It is embedded' in the dura and grooves the inner sur- 
face of the skull. 

400 



TOPOGRAPHY OF THE MIDDLE MENINGEAL. 



401 




Above the level of the zygoma, the artery divides. The posterior branch, 
the smaller, is directed upward and backward, and the anterior branch (Fig. 
304), the more important, ascends vertically to the fron to -parietal suture, 
which it follows upward, passing a httle posterior to it. As it reaches this 
suture, it gives off constantly a posterior branch. The anterior branch is ac- 
companied by veins which occasionally assume the importance of a sinus. 

The directions for trephining over the middle meningeal are quite definite 
but usually unnecessary to regard in emergency surgery, for it is a mistake 
not to follow the exterior indications and guides furnished by the traumatism. 
Still one should be able to locate these points read-'ly 

Two 'horizontal and two vertical lines 
are employed to locate the paths of the 
two branches of the middle meningeal. 
Draw the first (A) from the inferior 
border of the orbit along the zygoma to the 
inferior meatus. Draw the second (B) from 
the upper border of the orbit backward, 
and parallel with the first, ending beyond 
the line of the mastoid. To locate the 
path of the anterior branch of the middle 
meningeal, draw a perpendicular line from 
A upward from a point corresponding to 
the middle of zygoma and where it cuts 
B, is the point most advantageous for ex- 
posing the anterior branch. This vertical 
line is about two inches in length or ap- 
proximately equal to the length of the last two joints of the index finger. 
To locate the track of the posterior branch: from the .apex of the mastoid, 
draw a second vertical line upward; its point of junction with B indicates 
the path of the posterior branch. These lines may be marked off on the 
skin by tincture of iodine. 

Operation. — ^Provide, besides the ordinary instruments, Rongeur 
forceps, a mallet and chisel, or a trephine. Carefully shave the half 
of the head corresponding to the traumatism, or even better, the whole 
head. Sterilize the field. Scrub with soap and water, followed by 
ether, which in turn is followed by bichloride solution. There must be 
no relaxation in the disinfection, whether exploration is to be extensive 
or not, for asepsis is the best means of preventing a hernia of the brain. 

General Anesthesia. — Often the sensibility is so benumbed, the patient 
so depressed, that anesthesia is both unnecessary and dangerous. 
Chloroform is generally best for brain surgery, but ether is safer in 
these urgent cases with much shock. 

Incision. — The incision will vary with the conditions. We will 
26 



Fig. 304. — Outline of the middle menin- 
geal artery. (Veau, after Cuneo.) 



402 



URGENT craniectomy: TREPHINING. 



suppose three circumstances; (a) there is an extensive skin wound; 
(b) there is a bullet wound; (c) there is no wound of the soft parts. 

(a) If there is an extensive and ragged skin wound, it is better to 
enlarge it at once by crucial incision. This has the advantage of being 
rapidly done but has the disadvantage that it interferes with the blood 
supply of the flaps (Fig. 305). 

(b) If there is a bullet wound, make a "Z7" shaped flap with the 




Fig. 305. — Depressed fracture of the skull. Crucial incision. ( Veau.) 



bullet wound in the center, and which retains its attachment below 
the better to conserve the blood supply. 

(c) If there is no open wound, make the same sort of ''U" shaped 
flap with its pedicle downward, over the site of the contusion. 

Cut boldly to the bone if it is resistant. If the fragments are 
mobile under the scalp, proceed cautiously, but do not stop until on 
the pericranium. The incision will often traverse a zone which is con- 
tused and infiltrated, the various layers being indistinguishable. 

If possible, form the flaps first and then catch the bleeding points 



EXTRACTION OF SKULL FRAGMENTS. 



403 



along the edges of the flaps. In some cases it may be necessary to 
clamp a vessel before the incisions are completed. 

x\s soon as the bone is reached, hurriedly strip back the flaps, in- 
cluding the periosteum. The site of the fracture is now exposed 
(Fig. 306). One of two conditions presents: (i) there are depressed 
fragments which must be removed, or (2) there is a fissure without 
depression, but beneath the bone there is a clot to remove and a hemor- 
rhage to check. 

(i) The fragments are often superimposed in two layers and those 




Fig. 306. — Stripping back the periosteum to expose the field of fracture. (Veau.) 



of the internal table are usually the most extensive. In some cases 
the fragments are easily extracted, but in others the bony fragments 
are so wedged in that it is difficult to induce any instrument to pry 
them loose. Failing in this, notch the sound bone along the line of 
fracture with the chisel, and in this manner open up a way to intro- 
duce the elevator. Be careful not to further bruise the brain in ex- 
tracting the fragments, employing only horizontal traction. Never 
wrench or twist the fragments (Fig. 307). 

The deeper fragments are usually adherent to the dura mater and, 
if so, require to be stripped loose before attempting extraction. 



404 



URGENT craniectomy: TREPHINING. 



(2) If there exists merely a fissure, it will be necessary to trephine. 
At the possible site of the hemorrhage, create an orifice in the skull, 
either with the trephine or with mallet and chisel. 

Trephine. — (A) The ordinary Gait trephine may be employed. 
Begin by protruding its sharp point about one-sixteenth inch and 
boring it into the skull at the selected site. As soon as the cutting 
edge of the trephine has grooved the skull, retract the point and 
proceed to deepen the groove by rapid half rotations of the wrist. 
From time to time test the groove with the point of a probe to be sure 




Fig. 307. — Removal of the fragments. (Veau.) 

that one side is not cutting faster than the other. If there is any 
difference, regulate the pressure accordingly. Diminished resistance 
and increased blood flow indicate penetration of the outer table. 

The inner table is more resistant and when it is reached one must 
proceed more cautiously. When it is judged that section is complete, 
the trephine may be removed and gentle effort made to elevate the 
button. It the bone is completely divided, the button is easily removed. 

(B) Doyens' instrument is in less common use but is simple and 
efficient. It consists of a brace, a perforator, and burrs of various 
sizes. 



TREPHINING WITH MALLET AND CHISEL. 



405 



Begin by attaching the perforator and drilling a shallow hole, 
steadying the brace with the left hand. The instrument must always 
be kept perpendicular to the skull. Next replace the perforator with 
a burr and rapidly ream out the opening begun by the perforator. As 
before, one recognizes the approach to the diploe and the inner table. 
The burr pushes the dura before it without injury. A quadrilateral or 
circular flap may be outlined by additional openings and the chisel or 
rongeur used to complete the section of the flap. 

(C) The mallet and chisel may be used and while not so efficient 




Fig. 308. — Removal of the clot. (Veau.) 



as the trephine, will serve the purpose. Begin by cutting a narrow 
groove in the skull, deepening it gradually until the inner table is reached 
and divided. The chief point to be emphasized is that the chisel 
is to be held quite obliquely to avoid concussion and unexpected pene- 
tration. 

Detach the dura mater. Whatever the means employed, the dura 
is now exposed and if the opening, which should have a diameter of 
at least two inches, needs to be enlarged, the dura should be detached 
from the edge of bone and the chisel or rongeur employed. Enlarge 
so as to expose as much as possible of the middle meningeal artery. 



4o6 



URGENT craniectomy: TREPHINING. 



Treat the hemorrhage. Once the cranial cavity is well exposed, 
the next concern is the hemorrhage, (a) There is a clot to be re- 
moved; (b) a bleeding vessel to control. 

(a) The clot may be removed with the finger or with a dull curette. 
The amount of the accumulated blood may be astonishing but one 
must work patiently. The clot must be removed to the last particle; 
remember that toward the base there is the greatest abundance. 
The white and resistant dura mater must be exposed in every direction 
(Fig. 308). 




Fig. 309. — Ligation of the middle meningeal artery. (Veau.) 



(b) Next look for the bleeding vessel. A jet of blood may indicate 
the proper point at once and the vessel is caught with forceps and a 
ligature passed with a needle. (Fig. 309). If the bleeding point is too 
deep, the forceps may be left in position for twenty-four hours. More 
often perhaps, the source of the hemorrhage cannot be definitely de- 
termined and as soon as the compress is removed, the blood wells up 
from the bottom of the cavity. Depressing the head, the change in the 
stream's direction may reveal its source which is liable to be the middle 
meningeal vein; it is to be caught up and ligated like the artery. If 
the blood comes from a sinus, pack the cavity with sterile gauze. The 
hemostasis must be complete. If there is only slight, yet persistent 



AFTER TREATMENT OF TREPHINING. 407 

oozing, leave a gauze tampon for twenty-four hours. Suture the angles 
of the wound and apply a dry dressing. 

Another case, more rare: The dura mater is lacerated and the brain, 
more or less contused, is exposed. Catch the edges of the dural 
wound with forceps and, raising the membrane, gently wipe out the 
clots with sterile gauze. 

A mere slit in the dura may be repaired by catgut suture, but if there is 
loss of tissue, it is useless to attempt suture of this inelastic membrane. 
The hemorrhage must be cared for in the manner already described. 

Most trying are those cases presenting a subdural he?natoma. Tre- 
phining is completed and the dura is exposed but there is no clot. 
Instead, the dura, tense and darkened, bulges toward the orifice. 
Make a crucial incision in the dura or raise a flap with its base above 
and wipe out the exudate, usually diffused. Be very careful not to 
give additional injury to the contused brain tissue. Leave a strip of 
sterile gauze in the wound for drainage, removing it on the second day. 

After-treatment.- — ^Following the operation, it may be necessary 
to inject one or two quarts of salt solution in the first thirty-six hours. 
No alcoholic stimulants must be used. Keep the patient absolutely 
quiet, the head slightly elevated, and change the dressing as often as 
soiled. If sepsis occurs, open up the wound. If there is hernia 
cerebri, Treves advises a gauze pad saturated with alcohol held on 
under light pressure. 

Results. — The patient may die without regaining consciousness, 
owing to the shock of the traumatism, aggravated perhaps by the 
operation; for this reason, it is absolutely necessary to give as little 
chloroform, and to do the operation as rapidly, as possible. 

He may die the next day from persistent hemorrhage. He may 
die between the third and eighth day from septic meningitis, due to 
infection from the injury or the operation. Watch the course of the 
temperature in order to forecast sepsis. 

Finally he may recover and even then he may develop a Jacksonian 
epilepsy, delayed perhaps as long as ten years.* 

* It occasionally happens that the hemorrhage occurs on the side opposite the 
traumatism. There is nothing to do but repeat the trephining on the opposite 
side for the matter cannot be determined beforehand. 



4o8 URGENT CRANIECTOMY: TREPHINING. 

Trephining for Gunshot Wounds. — Every case of gunshot wound 
of the skull must be explored, though, of course, no trephining is 
necessary unless there is perforation or unless there are evidences of 
gunshot fracture without perforation. 

When it has been determined that there is perforation, raise a 
flap with the bullet wound in the center, as has been already described. 
The flap must be larger than the possible trephine opening in the 
skull. Enlarge the opening in the skull with trephine, chisel and 
mallet, or with rongeur forceps. Remove all fragments of bone and 
foreign matter, wdpe out the dural and cerebral wounds with sterile 
gauze. Be patient and persistent in this cleansing. Do not explore 
the bullet track or attempt to remove the bullet unless, of course, it 
is within easy reach. 

Regarding the indications generally for operations on the skull, 
following traumatism, Bullard (Boston Med. and Surg. Jour., Feb. 15, 
1906) advises immediate operation in the following cases: 

1. All compound fractures of the skull. 

2. Most cases of simple fracture, definitely diagnosed. 

3. All depressed fractures. 

4. All fractures with symptoms of cerebral hemorrhage. 

5. To these w^e may add all gunshot w^ounds. 



CHAPTER V. 
MASTOID ABSCESS. 

The tympanum, and likewise its accessory cavities, are normally 
sterile, but there are two highways by which infection may reach this 
site, the Eustachian tube and the external auditory canal. The 
Eustachian canal is the much more common route, the infection first 
gaining a foothold in the mucous membrane of the naso-pharynx, 
so that an inflammation of the mucosa of the middle ear is often only 
a step further in the ordinary pharyngeal catarrhal process. 

Finally the catarrhal inflammation may become a purulent one, 
in either case, running an acute or chronic course. Again, the pyogenic 
germ will not long limit its operation to the tympanum, but eventually 
invades the pneumatic spaces adjacent, the antrum and mastoid cells, 
and then, there may develop a mastoid abscess, a condition full of 
potential danger. The thin roof of the middle ear is the dividing line 
between the posterior and middle cerebral fossae, and through it, 
infection may reach the cerebellum or the middle lobe of the cerebrum: 
meningitis, epidural, cerebral, or cerebellar abscess is the immediate 
result. 

The mastoid cells are separated from the lateral sinus by a bony 
partition, so that through the small venous channels or by necrosis 
of the bony wall, infection may reach the sinus. Finally general 
infection and sinus thrombosis may ensue, followed perhaps by metas- 
tatic abscess. 

These are the actual dangers of mastoid abscess and one can never 
tell how fast the pathological process may extend, aided by bone 
erosion or by the escape of the infectious matter through apertures in 
the bone or by the blood vessels and lymphatics. 

Acute purulent mastoiditis then, is an emergency and every doctor 
should feel himself prepared to trephine the mastoid if it becomes 
his duty, and it is his duty if no one more skilled is at hand. 

409 



4IO MASTOID ABSCESS. 

How shall one recognize this emergency? 

The pain, sleeplessness, prostration, fever, together with the history 
of the case, point with a great degree of probability to the nature of 
the trouble. Now, if the examination adds certain other signs to 
these symptoms, the indications for intervention are definite: 

(i) ^ou find the upper and posterior quadrant of the ear drum 
(Shrapnell's membrane) bulging and perhaps the superior and poste- 
rior walls of the canal are swollen. 

(2) You find persistent tenderness over the mastoid process. 

(3) You may observe that a previously free discharge has suddenly 
diminished and this is an added warning that delay is dangerous. 

To repeat, the cardinal symptoms are pain, redness, swelling, bulg- 
ing of the drum, and fever. The first thing to do is a paracentesis. 

PARACENTESIS. 

Douche the auditory canal gently with warm, sterile water; co- 
cainize the canal with a 10 per cent solution and wait five or ten 
minutes. With the otoscope, expose the drum and locate the bulging 
area. Puncture it with a small, pointed bistoury, making an incision 
three or four millimeters long, downward and forward. 

There is nothing to fear. Even if the drum has spontaneously 
ruptured, it is often an advantage to enlarge the opening. Usually 
a few drops of pus escape. Follow with irrigation. 

If, at the end of twenty-four hours, the symptoms have not subsided, 
proceed without further delay to trephine the mastoid. 

Operation. — The operation is easy and without much danger if one 
but knows the anatomy (Fig. 310). The sigmoid sinus is more shallow 
in children than adults. Recall the situation of the spine of Henle, 
the facial nerve and the lateral sinus. The spine of Henle marks the 
upper limit of the external meatus-; one-quarter inch above it, is the 
middle cerebral fossa; the mastoid antrum is one-half inch posterior. 

Shave the temporo-parietal region and scrupulously prepare the 
field. General anesthesia is indispensable. 

Special instruments necessary are a Macewen seeker, a chisel (one 
centimeter wide), a small gouge, mallet, curette, curved periosteal 
elevator and probe. 



RELATION OF THE LATERAL SENUS TO THE MASTOID PROCESS 4II 




Fig. 310. — Landmarks of the mastoid. The square represents the area to be trephined 
the dotted lines the course of the lateral sinus. (Veau.) 




Fig. 311. — Incision for mastoid operation. (Veau.) 



412 



MASTOID ABSCESS. 



Incision (Fig. 311). — Begin at the apex of the mastoid and follow 
the curve of the external ear to the level of its attachment above. This 
incision reaches to the bone, and when operating on children be care- 
ful not to cut through the bone. Catch the bleeding vessels in the 
gaping wound. Rapidly denude the bone, an undertaking some- 
what difi&cult below where the sterno-mastoid is attached (Fig. 312). 

Introduce a sound into the external auditory canal to determine 
its direction. Expose the spine of Henle. 




Fig. 312. — Denuding the mastoid with the rugine. (Veau.) 

Trephine. Start the chisel vertically five millimeters behind the 
meatus; two or three slight blows of the mallet will be sufficient. 
In a child, a bistoury may be used. Make the second trace with the 
chisel horizontal and on a level with the spine of Henle. The third 
is parallel with the second and finally the fourth, parallel with the 
first, completes* the outline of chip. This fourth line of section is 
in the danger area, nearly over the lateral sinus. In making it, hold 
the chisel obliquely instead of vertically as in the first (Fig. 313). By 
slight and rapid blows, remove this chip. 



EXPOSING THE MASTOID CELLS. 



413 



If this does not expose the cells, deepen the opening carefully with the 
gouge. Pus will often be found at the first incision into the bony wall. 




Fig. 313. — Outlining the chip of bone to be removed. (Veau.) 




Fig. 314. — Exposing the lower mastoid cells. (Veau.) 

Introduce a seeker or blunt probe which will locate the various 
cavities and canals leading to the cells of the mastoid and antrum. 



414 MASTOID ABSCESS. 

Their coverings then are chipped off, or they may be merely 
curetted. 

Chisel below first (Fig. 314) and then with the guide, locate the 
posterior limit of the cells and chisel off the bone lying over the point 
of the guide. A trough may be trephined downward toward the tip. 
Remember that posteriorly there is the lateral sinus (Fig. 315). Do not 
stop until all the cells are freely exposed. 

When the mastoid cells are thus opened up, it remains to expose 
the antrum (Fig. 316). It lies in the direction upward and forward at 




Fig. 315. — Exposing the posterior cells. The lateral sinus must be avoided. (Veau.) 

what seems a considerable depth, one to three centimeters. Locate 
the cavity with the guide and enlarge freely. The mastoid cells and 
the antrum are now a single cavity. Carefully curette the necrosed 
bone and fungosities, but be very careful when curetting over the 
posterior wall, for the lateral sinus may be exposed. Throughout 
the operation, one may be disturbed by the hemorrhage, always con- 
siderable, and it will be necessary to sponge continually, for it is in- 
dispensable that one see what he is doing. 

Certain accidents may occur in the course of the operation. 

(i) The lateral sinus may be wounded, immediately recognized 
by the excessive hemorrhage, but do not be perturbed for it is easy to 



INJURY TO THE FACIAL NERVE. 



415 



arrest the bleeding. Pack the point or apply hot, moist applications 
with sterile gauze and continue the operation. If you find thrombosis, 
it will be necessary to open the sinus. 

(2) The cranial cavity may be opened, but neither is this partic- 
ularly serious. However, you should avoid, if possible, an injury 
to the meninges for there is danger of infection. Chisel discreetly, 
therefore, at the upper angle of the opening. 

If you do wound the dura, disinfect and tampon, but do not attempt 
suture. It is scarcely possible at that depth in a cavity so narrow. 




Fig. 316. — The operation completed, the guide is in the mastoid. (Veau.) 



The facial nerve may get in the way and if wounded, that is indeed 
a serious matter, for you can do nothing to remedy it. It is deeply 
situated and if you follow the guide, you are scarcely likely to reach it 
with the gouge. It is almost certain to be injured if the mastoid is 
fractured in the course of the trephining, and this will happen if the 
mallet and chisel are recklessly used. Injury to the facial nerve is 
really the one danger of the operation. Close approach is indicated 
by twitching of the facial muscles. 

Dressing and Subsequent Treatment. — Partially suture the wound and 
pack with iodoform gauze. The dressings are as important as the 
operation. If neglected, a fistula may form or the suppuration may 



4l6 MASTOID ABSCESS. 

recur. Instruct the patient that repair may require six to eight weeks 
or longer. 

On the second day after the operation, remove the gauze and irrigate 
with warm sterile water, dry carefully and repack methodically so 
that all the diverticula are filled. They must not be allowed to close 
over. Granulation from the bottom is indispensable. 

Change the dressing every other day. Repress excessive granula- 
tion with tincture of iodine or nitrate of silver. 

Keep the patient in bed for one week; keep the bowels open and 
regulate the diet. 



I 



CHAPTER VI. 
LAPAROTOMY FOR TRAUMATISM. 

The indications for laparotomy following traumatism are as follows: 

1. Perforating gunshot wounds. 

2. Perforating stab wounds likely to have wounded a viscus. 

3. Contusions of the abdomen presenting symptoms of dangerous 
lesions of abdominal viscera or vessels; not always definite but operate 
at once if you find these appearances following contusions: 

(a) The abdominal walls are resistant some distance from the 
injury; a progressive meteorism reaching the hepatic region; dullness 
over the iliac fossae or the flanks, indicating hemorrhage. 

(b) The pulse is weak and rapid and grov^ing worse. 

(c) The general condition of the patient is alarming, pallor, pain, 
excitement or delirium, subnormal temperature. 

But whether it be an open wound or a contusion, do not wait for 
the symptoms of peritonitis, for it will then likely be too late. The 
operation is delicate and dangerous in the hands of the unskilled, and 
yet the patient's life depends upon it. There is no time to send for a 
specialist unless he is right at hand, and as Veau says, it is better for 
the patient to be operated on early by an inexperienced surgeon, than 
to be operated on too late by the best surgeon in the land. It is an 
intervention in which one never knows what he is going to find. 

The steps oj the operation are as follows: 

(i) A laparotomy. 

(2) Search for the hemorrhage if there is blood in the abdomen. 

(3) Search for visceral injuries. 

General anesthesia is indispensable and ether is preferable unless 
compelled to operate in close quarters by lamp light. Every precau- 
tion must be taken not to aggravate shock; the limbs should be wrapped 
and the chest protected. The whole anterior abdominal wall must be 
27 417 



4i8 



LAPAROTOMY FOR TRAUMATISM. 



sterilized. Be prepared for normal salt injections, of ten necessary 
throughout the operation. 

(i) Laparotomy: Whatever be the site of the wound or contusion, 
make an incision in the middle line; below the umbilicus, usually; 
above, if the injury points to the epigastrium. The incision at first 
should be about three inches long. It may be necessary to extend it. 
Divide the skin and fatty tissues and catch up the bleeding vessels. 
Open the sheath of the rectus and look for the linea alba, but if not 
readily found, go through the muscle; it does not greatly matter. 

Divide the transversalis fascia and ex- 
pose the subperitoneal fatty tissue. It 
may be quite thick. 

The peritoneum will probably not 
be recognized by its appearance but 
rather by observing, the tissues gone 
through. It is usually bulging. One 
may be able to see free blood in the 
cavity by reason of its transparency. 

Catch up the peritoneum with dis- 
secting forceps and incise the cone 
thus formed, with the cutting edge of 
the scalpel turned away from the 
abdominal cavity, that the bowel may 
not be wounded (Fig. 317). Enlarge 
the small opening thus created and 
direct the assistant to seize the lips of the peritoneal wound with forceps. 
Pay no attention to the blood which may pour out but proceed 
rapidly to elongate the peritoneal wound with the scissors, protecting 
the bowel with the left index finger (Fig. 318). Remember the perit- 
oneum envelopes the bladder, so do not open the peritoneum down 
to the pubes, although the skin wound should be carried thus far in 
order to give the best view (Fig. 319). 

Carefully catch up the. lips of the peritoneal wound with forceps 
which may also serve as retractors; such control of the peritoneum will 
also facilitate its suturing at the end of the operation. It may now 
be necessary to push the anesthesia a little if there is much resistance. 




Fig. 317. — Incising the fold of 
peritoneum. (Guibe.) 



CONTROL OF THE HEMORRHAGE. 



419 



(2) Locate and check the hemorrhage. Do not be in a hurry to 
put a hand in the cavity but observe closely, sponging gently. The 
character of the fluids may be helpful in diagnosis. The examining 
finger may detect lesions or the injured viscera may push up into 
the wound. 




Fig. 318. — Enlarging the peritoneal opening with the scissors on the 
index finger to guide. (Guibe.) 



The hemorrhage may come from the following: (a) omentum; 
(b) mesentery; (c) the vascular organs, liver, spleen, kidney; (d) 
the vessels of the posterior abdominal wall. 

(a) The great omentum should be gently lifted out of the cavity. 
It may contain a hematoma and the divided vessels be hard to find. 



420 



LAPAROTOMY FOR TRAUMATISM. 



Tie them with No. 2 catgut. If the omentum is torn and lacerated, 
resect the injured portion (Fig. 303;. It may be split; the large 
vessels opened must be tied; the small will be controlled by the con- 
tinuous suture which should reunite the edges of the wound. If the 



\..J 




Fig. 319. — Enlarging the opening toward the pubes the bladder must 
not be wounded. (Guibe.) 



omentum is detached from the greater curvature, the stomach should 
be exposed, and the omentum sutured thereto. 

(b) The hemorrhage from the mesentery may be arrested in the 
same manner, though one may not find it until in the course of in- 
specting the gut. Mesenteric wounds often exist without visceral 
injury. In suturing the tear, the needle must be passed close to the 



TREATMENT OF WOUNDS OF THE INTESTINE. 42 1 

edges of the wound so that no vessel may be wounded or included in 
the tie. 

If its attachment to the bowel is disturbed for, say, more than three 
inches, or if it is necessary to tie a branch as large as the radial, the 
integrity of the corresponding section of gut is compromised and it 
will be advisable to resect. If unable to do that, treat it as the doubt- 
ful bowel is treated in strangulated hernia (see page 485). 

(c) If the hemorrhage proceeds from a wound of the liver, spleen 
or kidney, tampon methodically and firmly with sterile gauze. 

If the liver is ruptured extensively and tamponade has no effect, 
try deep suturing. If this does not succeed, the wound is probably 
beyond surgical aid. 

If the spleen is extensively lacerated, remove it. (See page 430.) 

(d) If the vessels of the posterior abdominal wall are involved, or 
the splenic, mesenteric or renal, it will often be very difficult to find 
the starting point of the hemorrhage for it is in the midst of a great 
clot. Begin by applying a large compress to the suspected point and 
make firm pressure. Following this, rapidly wipe out all the clots 
and reapply the compress. Raise its edge gradually and as each 
bleeding point appears, clamp it. It will often be impossible to 
ligate at that depth and forceps are left attached. The forceps are 
to remain twenty-four to thirty-six hours. These must be removed 
without violence. 

(3) Wounds of the intestine: Do not forget that intestinal per- 
forations are often multiple, are usually so after gunshot wounds, 
so that it is absolutely necessary to inspect the whole intestine that 
no wound may be overlooked. 

(A) Examination oj the Bowel. — The procedure must be methodical. 
Do not pick up first one segment and then another indiscriminately; 
in this way one part may be examined several times and another part 
not at all. 

Begin by picking up with forceps any part of the bowel that may 
present; these forceps will serve as a starting point and landmark. 
It will not hurt the bowel with its pressure as it includes in its hold 
only the serous and muscular coats (Fig. 320). 

Begin at this point, then, pulling up to view segment after segment. 



42 2 



LAPAROTOMY FOR TRAUMATISM. 



and as it is inspected, returning it to the cavity. The manoeuvre may 
be attended with difficulty especially if one is compelled to operate 
late, when peritonitis has begun and the partially paralyzed bowel 
is greatly distended. If several folds of the bowxl should escape and 
there is difficulty in returning them, the procedure as described on 
page 103 will be helpful. 




Fig. 320. — Examining the bowel. (Veau.) 

Begin by lifting up the abdominal wall by means of the retractors. 
Cover the refractory mass wdth a wide compress and then tuck each 
border of the compress into the wound, gradually working it into 
the abdominal cavity. It will carry the bowel along. Then carefully 
withdraw the compress. 

Examining thus the small intestine, one of its fixed points will 
finally be reached, either the cecum or the duodenum; return then 
to the forceps and work in the other direction.* 

*In tTie case of gunsHot wounds penetrating the abdomen from behind, the 
difficulties in locating the injuries may be greatly increased, a fact illustrated by 
the following case: 

On December 21, 1907, a colored man was brought to the City Hospital with a 
gunshot wound in the back, the bullet entering the right lumbar region about two 
inches from the middle line. Progressive abdominal distention and tenderness 
with symptoms of hemorrhage pointed to a visceral injury. He was immediately 
operated; the abdomen was opened below the umbilicus. The pelvis contained 
considerable blood but there was not the quantity expected. A systematic exam- 
ination of the intestine from the cecum to the duodeno-jejunal juncture revealed 



REPAIR OF INTESTINAL WOUNDS. 



423 



Whenever a perforation is found, it must be repaired before looking 
further. 

(B) Repair of the Intestinal Wound. — When an intestinal wound 
is located, seize its edges with two forceps, including only the serous 
and muscular coats, draw the part outside the cavity and isolate it 
with compresses and suture. 

(a) Non-perforating wounds are sufficiently repaired by two or 
three Lembert sutures. 

(b) Small perforating wounds, such as bullet wounds, must be 




Fig. 321. 



-The inclusive suture passed ; tied and Lembert suture 
passed; Lembert tied. 



repaired by suture in two layers (Fig. 321). With fine silk. No. i, 
make a suture which includes all three coats, serous, muscular and 
mucous (Fig. 322). If the wound is longer than two-thirds of an 
inch, use two such sutures, etc. These sutures are to be covered in 
and buried by the second layer, which involves only the serous coat 



no perforation. No opening in the posterior abdominal wall could be found be- 
low the level of the umbilicus. The incision was extended and the examining 
finger located a tear behind the stomach. At this time the patient's condition 
grew so bad it was necessary to cease the search and before the abdomen could be 
completely closed, he died. 

The post-mortem revealed a long tear in the transverse portion of the duodenum. 
The bullet had struck the transverse process of a lumbar vertebra, had deflected 
to the left, wounding the ascending vena cava and the duodenum, and had lodged 
in the anterior abdominal wall. The blood escaping from the vena cava had not 
emptied into the abdomen but had followed the vein along the spine and had flooded 
the posterior mediastinuin. 



424 



LAPAROTOMY FOR TRAUMATISM. 



(Lembert suture). In introducing them, begin at least one-half 
inch back of the first line and use either a continuous or interrupted 
suture (Fig. 323). 





Fig. 322. — The first layer 
of sutures include all coats. 

(Veau.) 



Fig. 323. — Applying sero- 
serous (Lembert) sutures. 
(Veau.) 



(c) Large Perjorating Wounds. — If the wound is an incised one, 
suture without refreshing the edges, but if it is contused or lacerated 
(Fig. 324) it will be necessary for repair to trim away to the sound 
tissue; but take care not to diminish the caliber of the gut. 





Fig. 324. — Tiimming away the 
bruised tissue. (Veau.) 



Fig. 325. — Transverse suture 
to prevent narrowing of the 
bowel. (Veau.) 



As before, beginning at one angle, introduce the first line of the 
suture, including all the coats and using, if possible, a continuous 
suture (Fig. 325). 



AFTER TREATMENT OF LAPARATOMY FOR TRAUMATISM. 



425 




AJI 



The second line of (Lembert or sero-serous) sutures must begin and 
end one-half inch beyond the limits of the first and the needle must be 
entered far enough away from the first line that the peritoneal surfaces 
may be well apposed and the first layer completely covered (Fig. 326). 

(C) Resectimt of the Gut. — If the wound involves more than two- 
thirds of the circumference or if there is a contusion of the whole or 
a large part of the segment, it will be necessary to resect and do a 
circular enterorrhaphy or some other form of anastomosis. If the 
operator cannot undertake that, then the gut 
must be treated as in the gangrene of strangu- 
lated hernia, making an artificial anus (see 
page 485). 

Drain the peritoneal cavity with a Micu- 
licz drain where there is oozing and with a 
drainage tube if infection is feared (see 
Chapter V. on drainage). 

Close the abdominal wall by three tiers of 
suture; the peritoneum with a continuous Fig. 326.— Applying Lembert 
suture of catgut, the muscles with chromicized 
catgut and the skin with silkworm gut. Apply a dry dressing. 

Subsequent Care. — Order complete rest and absence of food for forty- 
eight hours, not even excepting milk. To quench the thirst, let the 
patient suck a cloth saturated with water. Inject salt solution if 
there are signs of collapse. It will nearly always be expedient to give 
salt solution either by rectum or subcutaneously; in the worst cases 
by intravenous infusion. 

Change the dressing the following day. It will probably be satur- 
ated with bloody serum. On the second day remove the tampons 
and replace with smaller ones. On the fourth day remove the drain- 
age tube, if employed, and replace with smaller one, which may be 
dispensed with after the eighth day. 

Prognosis. — The prognosis will ' depend upon the extent of the 
injuries and the skill of the operator. 

Death may occur from hemorrhage or peritonitis shortly after the 
operation, or about the eighth or tenth day if the suturing has been 
imperfectly done. 



426 LAPAROTOMY FOR TRAUMATISM. 

Fecal abscess and fecal fistula may result, requiring a later operation, 
or which may eventually cure themselves. 

Complete recovery happily very often occurs and would be the rule 
if the doctor had the judgment or authority to operate within the 
first few hours after the traumatism. 

WOUNDS OF THE STOMACH. 

If the injury involved the upper pole of the abdomen, the stomach 
must be examined carefully. Extensive injuries are often overlooked. 
An escape of gas and bleeding may point to the situation of the lesion. 

Pick up the stomach with gauze to get a firmer hold and examine 
the anterior surface systematically. Repair any wounds, as in the 
intestine, by two rows of suture; the one including all the coats, the 
other, only the serous and muscular. 

Examine the posterior surface. To reach the posterior surface, 
Auvray insists upon a large incision in the gastro-colic omentum 
along the lower border of the stomach, for a large incision facilitates 
examination and does not compromise the vitality of any structure. 
If even then one cannot gain full access, he advises an exploratory 
gastrotomy (Revue de Chirurgie, Nov. 10, 1906). 

The posterior surface may be reached another way, by turning 
up the transverse colon and opening the transverse meso-colon. 

If there has been much loss of substance, it may be necessary to do 
a gastro-enterostomy. 

WOUNDS OF THE LIVER. 

If the nature of the abdominal injury leaves no doubt that the 
liver is wounded, it may be advisable to vary the procedure described 
from the first. A support under the back tilts the abdomen so that 
the intestine drops down toward the pelvic cavity and at the same 
time the liver is bulged forward and made more accessible. 

The incision beginning at the ensiform cartilage may follow the 
costal arch dividing, if necessary, the right rectus muscle. It may 
even be necessary, in order to reach the upper surface of the liver, 
to resect the tenth, ninth or eighth ribs. 

You may find on examination of the viscera that the liver has been 



TREATMENT OF WOUNDS OF THE LIVER. 427 

contused and there is evidently a hematoma formed beneath the cap- 
sule. It is better not to disturb it unless the conditions seem to 
indicate continuation of oozing. 

There may be an open wound of any ch'aracter or extent with great 
hemorrhage. One should attempt to catch up and ligate the bleeding 
points, employing a fine clip or artery forceps. The veins, as well 
as the arteries, will stand the strain of a ligature, but may need to be 
dissected loose from the liver substance before the ligature can be 
applied. 

If the patient is not too weak, attempt repair by suture. It is a 
little difficult but quite possible and certainly desirable. 

Employ a blunt-pointed needle and do not push it through boldly, 
but slowly, and as you push, gently oscillate the needle. In this 
manner, the point may slip by the vessels. Employ a large catgut 
suture, as a fine suture cuts through the soft tissue (Fig. 327). 

Van Buren Knott (Iowa Med. Journal, Oct., 1907) recommends 
inserting a strand of catgut parallel with the liver wound, tying the 
ends of the strand over small skeins of catgut to prevent tearing. 
Transverse interrupted sutures aie then passed so as to include the 
parallel sutures first passed. 

Failing to suture, there is nothing left but the tamponade, and this, 
of course, is the only thing available in lacerated wounds. 

Wathen, of Louisville, even advises (Int. Jour. Surgery, July, 
1906) that the average operator use the tampon from the first to save 
time and trouble. The gauze must be packed into the wound with 
firmness to prevent further hemorrhage and its end brought to the 
external wound that it may be subsequently removed. 

Haynes, of New York (Annals of Surgery, July, 1907;, describes 
a case illustrative of some of the difficulties of treatment and the 
sequel'e of liver wounds. 

Patient, a man of twenty years, was brought to the Harlem Hospital 
with gunshot wound just below the tip of the ensiform cartilage. 
The bullet was found to have traversed the liver from before back- 
ward, and it was necessary to get at the wound of exit. 

From the median incision, a second incision was made transversely, 
dividing the right rectus and the seventh and sixth costal cartilages. 



428 



LAPAROTOMY FOR TRAUMATISM. 



The falciform ligament was also divided. With strong traction upon 
the costal arch, the posterior wound could be reached and felt but not 
seen, readily admitting two fingers. 

By the sense of touch, an -iodoform wick was packed into this wound 
and a smaller one introduced into the anterior wound and both 
brought out through the abdominal incision. This did not entirely 




Fig. 327. — Suture of the liver. (Moynihan.) 



control the hemorrhage and so the liver was forced up against the 
diaphragm and held by a large Miculicz tampon below the liver. 

The rectus was sutured. The peritoneum was repaired with the 
falciform ligament included; the abdominal walls sutured above and 
below the gauze wicks. 

On the tenth day the tamponade was removed; and a few days 



SUTURE OF WOUNDS OF THE PANCREAS. 



429 



later were removed the gauze wicks, for which rubber tubes were 
substituted, a discharge of bile and pus being present. 

At the end of the third week it became necessary to secure addi- 
tional drainage and the ninth rib was resected in the axillary line, 
where, in the meantime, the bullet had been located; the costal and 
phrenic pleura were sutured, and the pleural cavity thus shut off. 
The diaphragm was opened, the pus drained out and a long tube 
passed from the anterior to the posterior abdominal wounds, and a 
smaller one left in the posterior wound. 

The progress of repair was slow but sure, five months elapsing 
before the cure was complete. 

WOUNDS OF THE PANCREAS. 

Do not forget to examine the pancreas in wounds of the upper 
zone of the abdomen. Reach the pancreas from above the stomach, 
opening through the gastro-hepatic omentum. 




Fig. 32J 



Fig. 329. 



Figs. 328 and 329. — Method of suture of a wound in the pancreas. Two or three deep 
sutures of stout catgut or silk are passed, arid the wound-surfaces drawn together. The 
wound-edges are then sutured with fine catgut sutures. (Moynihan.) 



Carefully mop out the fluids, blood and pancreatic juice. Pack 
around the site with compresses and try to suture. Sometimes two 
or three deep sutures will coapt the wound surface and completely 
check the hemorrhage. If the tail is much crushed, resect it and 
suture the stump. Use gauze and tubal drainage. If the patient 
does not die, he may have a subphrenic abscess (Fig. 328, 329). 



430 LAPAROTOMY FOR TRAUilATISM. 

WOUNDS OF THE SPLEEN. 

Any but the slightest wound of the spleen is universally and rapidly 
fatal from hemorrhage. One naturally thinks of suturing. If that 
and tamponade are not effective to stop the bleeding, it is indicated 
to try to remove the viscus. This is not difficult if there are no ad- 
hesions, though, if there are, failure is almost certain. Under such 
circumstances, as Moynihan suggests, the only thing left is to pack 
with gauze, soaked, if necessary, in adrenalin solution. 

Noetzel (Beitrage Z. Klin. Chirurg.) reviews his experience with 
six cases in which he removed the spleen for injury and concludes 
that splenectomy is the only safe way of securing hemostasis. Suturing 
and tamponing may arrest bleeding for a time but there is danger 
that it will return. 

Holliday, of Portsmouth, Virginia, reports a case illustrating the 
subject (Virginia Medical Semi-monthly Journal, January ii, 1907); 
patient, boy, age 15, was struck in left side by a flying pulley, fracturing 
his arm in several places and contusing the abdominal wall. His 
condition shortly became serious; temperature subnormal, absolute 
dullness on the left side and marked rigidity. Immediate operation. 
The patient was almost eviscerated before the bleeding could be 
located, but which was finally found to proceed from the lacerated 
external surface of the spleen; a splenectomy was quickly done and 
the abdomen closed without drainage. Convalescence w^as easy 
and uneventful. 

Splenectomy. — The operation following rupture generally finds 
the incision made in the middle line on account of the indications for 
hemorrhage. 

The spleen is brought up into view and delivered from the abdom- 
inal cavity, avoiding any strain upon its pedicle, for the veins have 
extremely thin w^alls. 

Ligate and divide the pedicle. Transfix the pedicle with a double 
ligature and tie each half separately, and finally tie the whole pedicle 
in a single ligature. The pedicle is next divided, the spleen removed 
and its bed examined for any bleeding points. The under surface 
of the diaphragm is very likely to present some oozing. 



EXTRA-PERITONEAL WOUNDS OF THE KIDNEY. 43 1 

Fiske, of Brooklyn, describes a case which illustrates the variations 
in the procedure. (Annals of Surgery, Jan., 1908.) 

A man, of twenty-five years, was brought to the Kings County 
Hospital, with a bullet wound in the left side corresponding to the 
spleen. The symptoms pointed to visceral injury and intra-abdominal 
hemorrhage. An incision was made over the outer border of the left 
rectus muscle from the costal arch to a point midway between the 
umbilicus and symphysis. The stomach and intestine were found to 
be uninjured. A perforation in the transverse meso-colon was re- 
paired but the hemorrhage continued. A transverse incision was 
made and the spleen examined, revealing a rent which admitted two 
fingers. The spleen was pulled up into the wound, the pedicle clamped 
and ligated en masse. After removing the spleen, the vessels were 
ligated separately, the abdomen was flushed with saline solution, 
a small gauze drain left in contact with the stump, and the wound 
closed with through-and-through silkworm gut sutures. The tem- 
perature subsequently did not rise above 100°. The drain was 
permanently removed on the fifth day. The patient left the hospital 
at the end of the third week, entirely recovered. 

WOUNDS OF THE KIDNEY. 

If while examining the vis( era in the course of the laparotomy, 
you find a ruptured renal pelvis or a seriously lacerated kidney bleed- 
ing into the peritoneal cavity, remove the kidney. Make a longitu- 
dinal incision in its peritoneal covering, strip the organ out of its bed 
and, lifting toward the surface, free the pedicle. 

Ligate the ureter first and then, if possible, each of the vessels 
separately. If the oozing persists, leave a Miculicz drain or a rubber 
tube. 

Intra-peritoneal rupture without injury to other viscera is very rare. 

Extra-peritoneal wounds of the kidney do not, as a rule, require 
intervention. 

That the kidney has been involved will be suggested by pain, 
frequent micturition and bloody urine. 

,Rest, morphia and limited diet are the special indications. 

, Eliot (American Journal Surgery, Nov., 1906) has observed twelve. 



432 LAPAROTOMY FOR TRAUMATISM. 

cases of subcutaneous rupture of the kidney. In seven cases there 
was not sufficient extravasation to make a perceptible tumor and the 
diagnosis was made by the hematuria and the tenderness over the 
kidney and persistent rigidity for a number of days. 

In the remaining cases a well-defined tumor appeared in the ilio- 
costal space, becoming more sharply outlined as the rigidity dis- 
appeared. In five or six weeks, the tumor disappeared. In no 
instance was operation necessary. 

In such cases of extra-peritoneal rupture as require operation, the 
lumbar route should be chosen. Operation is indicated from the first 
if the violence was known to be great and a large tumor forms im- 
mediately. An operation is indicated at any time symptoms oj sepsis 
appear. 

Morris Miller reports a case (Annals of Surgery, Feb., 1908) of a 
man who fell, striking his left side over the lower rib. He felt faint 
and almost immediately passed a quart of blood by the urethra and 
later, many clots. Miller saw him at the hospital an hour and a half 
later. There was no shock but the side was rigid and tender and an 
indistinct dull mass could be felt in the loin. An oblique lumbar 
incision revealed an extensive rupture of the kidney with much hemor- 
rhage. Wicks of gauze were placed in front and behind the kidney 
and the ruptured segments pressed together. The patient did well, 
the hemorrhage gradually ceased, though twice after the fifth day 
blood appeared in the urine. On the twelfth day the packing was all 
removed and the opening finally healed. Gibbon, commenting on 
the case, remarks that hemorrhage severe enough to require operation 
does not usually mean injury sufficient to require nephrectomy. The 
question of nephrectomy must be decided when the kidney is exposed. 

Stewart adds that the two early indications for operation are a 
progressively increasing hematoma and constitutional symptoms of 
hemorrhage. In several cases of moderate bleeding he had operated 
and afterward been sorry he had interfered. 

WOUNDS OF THE BLADDER. 

Wounds of the bladder, if not previously suspected from the nature 
of the abdominal injuries, are inferred from the presence of urine in 



REPAIR OF WOUNDS OF THE BLADDER. 



433 



the peritoneal cavity. Sometimes the rent is hard to locate. Inject 
the bladder with normal salt solution and observe its mode of entrance 
into the peritoneal cavity. 

The wound is to be repaired by two rows of sutures, the first of 
catgut involving all the coats except the mucosa; the second, of silk, 
includes the peritoneum alone after the manner of the Lembert suture. 




Fig. 330. — Repair 01 ruptured bladder. Applying through and through sutures. Subse- 
quently Lembert sutures will be appHed and finally the parietal peritoneum will be repaired 
beginning at point of reflection onto the bladder. Peritoneum retained by forceps. (Lejars.) 

The stitches of both rows must be closely placed to seal the wound. 
The result may be tested by filling the bladder with normal salt solu- 
tion, and any defect repaired (Fig. 330). 

A catheter should be left in the bladder for drainage and the siphon- 
age kept up for two or three days. Subsequently the bladder should 
be emptied by aspetic catherization for a few days longer. The 
peritoneum should be drained for the first forty-eight hours. 
28 



434 



LAPAROTOMY FOR TRAUMATISM. 



This mode of treatment applies to the intraperitoneal wounds of 
the bladder. The extraperitoneal wounds should be treated on the 
same principle, but often, under such circumstances, the operator 
must be content with supiapubic drainage until the wound has healed. 

WOUNDS OF THE URETER. 

If it is discovered that the ureter is wounded either by the trauma 
or in the course of the operation, an effort should be made at repair. 
Several methods are available. If the injurv does not amount to 






Fig. 331. — Van 
Hook's ureteral an- 
astomosis (Binnie). 



Fig. 332. — Van Hook's 
ureteral anastomosis. 
(Binnie.) 



Fig. 333.— Anasto- 
mosis completed. 
(Binnie.) 



complete division, a few perforating sutures followed by Lembert 
sutures may succeed. Small wounds usually heal readily, but it is 
safer to use drainage. 

If the separation is complete, both ends of the torn ureter may be 
ligated, or the kidney may be removed, but naturally it is preferable, 
if possible, to establish an anastomosis. Under various circumstances, 
the proximal end may be anchored in the bladder or in the bowel, 
or the two ends may be brought together. 



ANASTOMOSIS OF THE URETER. 435 

Van Hook's termino-lateral anastomosis is generally applied. 
The technique may be briefly described in this wise: 

Ligate the distal portion one-quarter inch from the end and make 
a longitudinal slit double the diameter of the tube in length. Split 
the proximal end also for one-quarter inch, beginning at the free end. 

Pass the sukires. Employ a long catgut suture threaded on a 
needle at each end. One-eighth inch from the end of the proximal 
portion of the ureter, pass the two needles from without inward 
(Fig. 331). Carry the two needles through the split in the distal 
portion, into the lumen and let them emerge one-half inch below 
the end of the split (Fig. 332). Tighten the suture, which will 
have the effect of invaginating the upper segment in the lower 
(Fig. 333). Around the line of contact run a Lembert suture, and 
cover with omentum or peritoneum. 



b 



CHAPTER VII. 

APPENDICITIS. APPENDICEAL ABSCESS. PURULENT 
PERITONITIS.* 

Inflammation of the appendix presupposes two factors, lowered 
resistance and a pathogenic germ. 

The lowered resistance of the appendiceal tissue may find its 
origin in many diverse conditions involving its morphology, anatomy 
and physiology. It is generally agreed that it is an organ undergoing 
a retrograde metamorphosis, or, at any rate, one adapting itself to 
new functions. 

There is a small facility for compensatory circulation if its main 
artery is blocked, and, in consequence, it is exposed to vicissitudes of 
nutrition. 

Owing to its varying position, it is brought into contact and may 
acquire connections, vascular and lymphatic, with other abdominal 
and pelvic organs and structures and, by this means, be the recipient 
of pathogenic bacteria that had not elsewhere found a favorable soil. 

The pathogenic organisms which under favorable conditions may 
here develop and produce various grades of destruction are the bacillus 
communis coli, the streptococci, staphylococci, and others less frequent. 

Whatever part each of these causative agents may play in its develop- 
ment, the fact remains that appendicitis is one of the frequent and one 
of the most dangerous and treacherous diseases with which the general 
practitioner has to deal. 

Diagnosis. — The diagnosis is not difficult in the typical cases, 
but exceptionally may be extremely difficult, or even impossible, 
until the progress of the symptoms has been observed. 

A diagnosis should never be made from the mere presence of what 

* So important is this subject to the general practitioner, that he should be satis- 
fied to have and study no works less complete than the classic volumes of Deaver 
or Kelly. 



DIAGNOSIS or APPENDICITIS. 437 

are regarded as the cardinal symptoms; not until each symptom and 
sign has been weighed and accorded its proper significance, and all 
other possible conditions excluded, should it be decided definitely 
that the case is or is not acute appendicitis. 

To discuss briefly the symptoms upon which one must rely: the 
pain in the milder catarrhal cases is limited usually to the right iliac 
fossa. In the ulcerative type, with sudden onset, or the perforative 
type, it is very likely at first to be general over the abdomen, but after 
a few hours, is rather definitely localized in the right side. In the 
gangrenous cases, it may be absent in one case or severe in another, 
depending upon the degree of active peritoneal inflammation. 

Rigidity of the right rectus abdominis and pelvic muscles is an 
important sign, and its degree is some index to the amount of perit- 
oneal involvement. 

Gastric disturbance, nausea and vomiting are fairly constant occur- 
rences in the first stages of the attack, but last only a short time. 
T. B. Eastman (Ind. Med. Jour., Jan., 1907) has very strongly 
emphasized the frequent connection between the chronic forms of 
appendicitis and those appearances of gastric indigestion vaguely 
grouped as "stomach troubles." 

Constipation is almost the rule, and Kelly adds further that it may 
amount to an actual obstruction. Only rarely does diarrhea appear 
with the attack, and if it does, may be regarded as indicating a grave 
form. Most rare of all is it for an attack even of the mildest type, 
to run its course without some aberration of bowel action. 

Tenderness on pressure is a symptom upon which alone the diagnosis 
is too often made. It is scarcely possible for it to be wholly absent 
and yet it can by no means be relied upon to indicate the severity 
of the attack. Rosving (Central. Blatt. f. Chirurgie, October 26, 
1907) states that pressure on the left McBurney point always elicits 
pain in appendicitis but not in other cases. 

Robert Morris (Am. Jour. Surg., Jan. 25, 1908) adds something 
to this phase of the diagnosis. He claims that tenderness upon pressure 
over a point opposite the umbilicus in the line of the anterior superior 
spine of the ilium has a special significance and is due to involvement 
of the lumbar ganglia. Thus Morris' point on the right side will be 



438 APPENDICITIS. PURULENT PERITONITIS. 

tender in appendicitis. If that point on both sides is tender, the 
trouble is located in the pelvis. 

Tumor. — It is folly to wait for this sign to complete the diagnosis, 
for it means the certainty of a complicated pathology. It means 
peritoneal involvement with plastic exudates, or a pus formation, or 
both. 

Disturbance oj Pulse and Te^nperature. — There is no other grave 
disease perhaps, in which the pulse and temperature make such 
limited excursions. The temperature in the most serious cases may 
not reach 103°. Its elevation is in no wise significant. The pulse 
in the milder cases holds a certain ratio with the temperature. A 
temperature of loi, for example, should be accompanied by a pulse 
rate of 90 to 100. Any marked disturbance of this ratio is extremely 
significant; whether it is a low temperature with a rapid pulse or a 
high temperature with a slow pulse," the outlook is ominous. H. O. 
Panzter, from extended clinical" experience, insists that we must rely 
largely upon the rectal temperature in making a differential diagnosis, 
and that the temperature should be invariably taken by both mouth 
and rectum. The temperature by mouth in such cases may be very 
deceptive. 

Such, very briefly, are the principal symptoms and signs which, 
taken collectively, must serve to distinguish the disorder from acute 
intestinal obstruction, ovarian or tubal inflammation, cholecystitis, 
typhoid fever, pneumonia, and other acute diseases. 

There is not much danger at the present time, so prominently is the 
subject before the profession, that an appendicitis will be overlooked. 
Only too often is an innocent appendix held to be the cause of the 
illness in hand. Edmund Clark (personal communication) cites a 
number of instances, quite recently, where called to operate, he has 
found a lobar pneumonia, and nothing more. 

It is an appendicitis, but what is its character? Is it mild or 
dangerous? is it a simple catarrhal trouble which will soon subside, 
or is it potentially a gangrenous process with general peritonitis ahead ? 
These are the questions which confound the doctor and upon their 
answer rest the prognosis and treatment. 

Four varieties are described. 



VARIETIES OF APPENDICITIS. 439 

(i) Catarrhal appendicitis, in which the mucosa alone is involved, 
the predisposing causes are easily relieved, and the pathogenic agent 
is of a low order of virility. Neither local or constitutional symptoms 
are severe and the attack very shortly subsides. 

(2) In the ulcerative type, the process extends deeper and involves 
the muscular and perhaps the serous coat to some extent and there 
is produced a mild form of peritoneal inflammation. There is usually 
a diffused swelling of the w^hole appendix. 

(3) Perforative appendicitis, in which there is local destruction of 
all the coats and communication with the peritoneal cavity, is due to 
a sudden and virulent infection or an acute exacerbation of a slumber- 
ing process and begins abruptly with intense pain; and in a short 
time ends in peritoneal suppuration, local or general. 

(4) Gangrenous Appendicitis. — This form beginning as such is the 
most treacherous, for often the symptoms are in no wise proportionate 
to the seriousness of the case. Death is impending, and yet neither 
the pain, pulse, nor temperature gives due warning. There is ab- 
solutely no w^ay at this present time by which the doctor may recognize 
this condition de novo. It may be imagined that such a condition 
arises from sudden interference with the blood current to the organ, 
while infection plays the lesser part. On the other hand, gangrene 
which ensues from virulent infection begins at once with the char- 
acteristic symptoms of appendicitis added to those of sepsis and 
peritonitis. 

It is from the point of view of these pathological variations that 
the most diverse opinions as to treatment have arisen. 

It is evident that nature, unaided, may be able to take care of the 
milder type. It is a clinical fact that nature by means of her own, 
may sometimes control and keep the inflammation within bounds, 
even in the more dangerous cases. By means of plastic exudates, she 
walls off and limits the suppurating area and later provides a safe 
means of escape for the products of suppuration. But unfortunately, 
such a happy issue can never be depended upon. On the contrary, 
the suppuration is more likely to become dift\ise and there presents 
the picture of purulent peritonitis and the imminent prospect of a 
fatality. In such a case one loses sight of the local symptoms. 



440 APPENDICITIS. PURULENT PERITONITIS. 

The abdomen is rigid, tympanitic and everywhere exceedingly 
tender. The temperature is high; the pulse rapid; the tongue coated, 
brown and fissured; and as the disease progresses, the symptoms of 
circulatory collapse appear. The temperature then becomes sub- 
normal, the pulse almost uncountable, and the features pinched and 
anxious, until finally a mild delirium wdth pleasant hallucinations 
ushers in the end. 

The infection may be so severe, the toxemia so profound, that the 
patient may die of septic peritonitis before pus has had time to form. 
Indeed,' death may come from sepsis before the ordinary signs of 
inflammation appear. 

Such may be the outcome of what appears to be the mildest case. 
It is this prospect and the attendant uncertainties which have led 
many doctors to regard appendicitis as an emergency to be operated 
upon as soon as the diagnosis is made. As Pfaff, of Indianapolis, puts 
it, the difference between the mortality of i per cent in the very 
early operations, and that of 15 to 30 per cent in the abscess stage, 
is so frightful that, in comparison, an occasional unnecessary oper- 
ation is of no consequence at all. If we are to fulfill our obligations, 
w^e must act vigorously and today. 

This is undoubtedly a safe rule in the practice of the skilled operator, 
w^ho has at his command all the facilities of the aseptic operating 
room and trained assistants. 

The case is quite different wdth the general practitioner, remote 
from these accessories. Moreover it is known that 80 to 85 per cent 
of these cases recover without operation. Even for the relapsing 
form, Treves says that much may be done by medical means, diet, at- 
tention to the bowels, and by placing the patient under conditions 
more favorable to a state of peace within the abdomen. 

Whatever may be proper in hospital practice, it certainly cannot 
be imposed on the general practitioner that he operate at once. Even 
in connection w^ith the skilled surgeon, it may be said that his tech- 
nique has not yet reached such a degree of perfection that an operation 
is always safer than the milder form of appendicitis unoperated. 

The doctor then will face his responsibility, a heavy one truly, 
knowing there is much to be accomplished by medical means and 



TREATMENT OE APPENDICITIS. 44 1 

yet hoping that he will have the judgment to recognize the failure of 
his art and nature, and the will to resort not too late to more radical 
measures. 

Assume that the diagnosis is definitely made; assume that no sur- 
geon is within beck and call (for appendicitis is strictly a surgical 
disease), what will you do ? It is evident at once that this is a clinical 
hypothesis, and the question is to be resolved on a clinical basis. 

I. You see the case from the first. The attack begins mildly or 
with only moderate severity; there was perhaps a single attack of 
vomiting; the pain, abdominal tenderness and rigidity are not marked, 
and the patient's general condition is good. 

Under these circumstances, as Lejars says, it is perfectly legitimate 
to institute a medical treatment, in the meantime holding the case 
under the strictest surveillance. But this formula is null without the 
last provision. 7/ the march of the disease cannot he watched, it is 
better to operate at once, and this rule may as well be made to apply to 
any case in which delay might otherwise be counselled. You decide 
to try medical treatment but in what form? Like many others herein 
involved, the question brings forth a varied response. 

Under these circumstances one may follow the plan of ^^immobili- 
zation, " which Lejars and others so highly praise. But to be effective, 
it must be rigorously and consistently applied. 

Keep the patient absolutely quiet in bed. Give no purgatives — 
and this means give neither calomel or oil. Give no enemas. Sus- 
pend nourishment absolutely, relieving thirst by a few drops of water 
frequently given. 

Ice to the Abdomen. Not a handful of ice in a little bag applied over 
the iliac fossa, but two or three large bags covering the whole abdomen 
below the umbilicus and refilled as the ice melts. 

Opium, in \ grain doses in pill form every two hours for an adult; 
but it must not be pushed to the point of annulling all pain and sus- 
pending the functions of the kidney. 

It is far from being the rule that the practitioner remote from the 
larger towns can have ice at his command. Likewise opium in the 
hands of the inexperienced may be a two-edged tool. He must often, 
therefore, depend upon other modes of procedure, and for these, 



442 APPENDICITIS. PURULENT PERITONITIS. 

there is no lack of eminent authority. Under the circumstances in- 
dicated, begin with small doses of calomel frequently repeated, until 
a grain or two is taken, and follow with small doses of castor oil or 
larger doses of albolene until the bowels have moved freely. If the 
bowels are slow to move, supplement these internal remedies with 
enemas of normal salt solution. Apply hot fomentations to the 
abdomen, flannels wrung out of hot water and sprinkled with tur- 
pentine. Cover the hot flannels with several additional thicknesses 
and apply hot water bottles filled with boiling water, and cover the 
whole to retain the heat. As the water cools, withdraw one by one 
the various layers so that the temperature may be maintained at the 
highest point of comfort. Hot kaolin cataplasms often render service. 

As Oschner commands, food must be withheld absolutely, and if 
there is much gastric disturbance or pain, the stomach should be 
washed out. Opium is contraindicated under this form of treatment, 
for it is the purpose to cleanse the bowel. 

McGrath, of New York, probably expresses the prevailing opinion, 
summing the matter up in this wise (Medical Record, Feb. i, 1908): 

" Only in the catarrhal cases can there be any question as to treat- 
ment once the diagnosis is made; whether it is better to operate without 
delay, or seek to avail oneself of the advantage of an interval oper- 
ation. If sure of the character of the lesion we may temporize; it will 
do no harm watching the patient carefully for any sign of danger. 
Many of these cases resolve without going on to suppuration or gan- 
grene and therefore escape operation during the acute attack. Nature 
may be assisted in her efl'orts at spontaneous cure in these cases by 
enjoining complete rest, withholding all food and permitting only 
water to be taken, and by smah repeated doses of calomel and sodium 
bicarbonate. An ice bag may be applied over the region of the 
appendix. But if there is any doubt as to the exact pathological 
condition, operation should be advised unless marked contraindi- 
cations exist." 

George J. Cook, of Indianapolis, who has had as much experience 
with this disease as anyone in the ^Mississippi valley, does not operate 
in mild attacks of primary appendicitis. If it is a second attack, he 
operates without delay. He says that not infrequently a mild catarrhal 



TREATMENT OF APPENDICITIS. 443 

appendicitis does not recur. In such cases, he puts the patient at 
rest. He unloads the bowels with enemas merely. If the attack 
follows overeating, he employs a mild saline primarily. Nothing 
but water is permitted. As an intestinal antiseptic, he gives five 
grains of carbonate of guaiacol three or four times in the twenty-four 
hours. If the patient should complain much, he gives small doses of 
opium, after the diagnosis is made. He gives it to quiet the pain and 
not the peristalsis, asserting that the bowel will of itself be quiescent 
if empty. Ice bags applied to the abdomen as a routine measure 
represents to him the chief element in the relief of pain and control of 
inflammation. 

Note that whatever the form of treatment, the case must be narrowly 
watched. If the pulse and temperature remain in harmony; if the 
abdominal tension and tenderness tend to grow less; if the bowels 
move and gas escapes per rectum; if the general condition is good; 
there is ground to expect a satisfactory termination, but no excuse 
to relax one's vigilance. 

No nourishment should be given by mouth until defervescence is 
complete, and after that a liquid diet should be maintained for one to 
two weeks, depending upon the severity of the attack, and rest in bed 
as well. At the end of a few weeks, the appendix should be removed. 

But the progress of the disease may suddenly change. All the 
symptoms may become aggravated and the dangerous nature of the 
case become at once obvious — immediate operation is indicated; 
or the change may be insidious (unsuspected by the careless observer) 
and in this instance the chief reliance must be placed upon the pulse. 
If the pulse is rapid and weak with a falling temperature, or if the 
pulse falls to 50 or 60 with a rising temperature, in other words, 
if there is any marked divergence between pulse and temperature, 
again the indications are to operate at once. To repeat, any marked 
aggravation of the symptoms after improvement once begins, or the 
occurrence of any marked disparity between pulse and temperature, 
however benign the other symptoms may be, are indications for 
operation without delay. 

II. Another case: You have watched the case but the temperature 
has persisted and beyond, say the sixth day, when t4iere should be a 



444 APPENDICITIS. PURULENT PERITONITIS. 

marked improvement, you find the temperature rising or fluctuating, 
the pain increasing, a tumor forming most painful at its center. In 
this case also, the indication is for immediate operation. 

III. Suppose you see the case only at the end of several days, 
during which time the disease has run a neglected course. May one 
at this time, with any effect, apply a medical treatment, or should 
one resort at once to an operation? The question can only be an- 
swered after a careful consideration of the history of the case, such as 
the patient or his attendants can give, and a thorough investigation 
of the present symptoms. Only when the case is obviously benign, 
can one take the responsibility of further delay. For example, if 
the pulse and temperature are in accord, if the tenderness and tym- 
panitis are diminishing, then nothing better can be done than to 
follow the rules with regard to rest and diet already laid down. Yet 
one must be ever mindful of the treacherous character of certain forms 
of septic attack. 

Again, you find the disease progressing and in the active stage of 
the third, fourth or fifth day, with no indications of beginning im- 
provement, but the symptoms are not aggravated, and there is a plastic 
exudate without softening: again it may be said that under these cir- 
cumstances, it is legitimate to wait. 

Any continuance of the fever beyond the eighth or tenth day, even 
though the pulse is good and the exudate has not softened, is a matter 
of grave suspicion, and with the least enlargement of the tumor, or 
disturbance of pulse, operate without delay, and it is more than likely 
you will find a large abscess. 

IV. In any case, at any stage, if a diagnosis of abscess can be made 
out — a palpable fluctuating mass, in the iliac fossa — whatsoever the 
other symptoms may be, there is but one indication, immediate 
operation. No practitioner to whom the task falls, whatsoever his 
ability or training, can do anything else and do his duty. Even though 
you cannot detect fluctuation, but by vaginal and rectal examination 
determine that the mass is doughy and painful, operate and you will 
almost certainly find pus. 

V. Finally, even if the case has progressed to a general peritonitis, 
it is one's duty to operate unless the patient be practically moribund, 



OPERATION FOR APPENDICITIS. 445 

and even in these cases, as Lejars puts it, operation has rescued a 
certain number of patients from the very jaws of death, for without 
operation, they would inevitably have died. 

Even though the diagnosis is not definitely established and one 



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Fig. 334. — Vertical incision through skin, aponeurosis and sheath of rectus. 
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considers the possibility of meeting with a tubercular peritonitis 
or a salpingitis or similar condition, yet the rule should be to operate 
in any case of doubt. 

Operation. — Two operations will be described: A, when no pus or 



446 



APPENDICITIS. PURULENT PERITONITIS. 



other complications is expected; B, when pus, localized or diffused, 
is a certainty. 

A. Incision. — Begin one inch above or two inches below the line 
connecting the anterior superior iliac spine with the umbilicus. The 





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FiG- 335- — Rectus drawn inward. Posterior layer of sheath and transversalis fascia 
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incision crosses this line one-half inch to its inner side of its middle 
point and follows, practically, the outer border of the rectus ab- 
dominis. 

Divide first the skin and fat, and expose the aponeurosis of the ex- 
ternal oblique. Divide next the aponeurosis and under one lip is the 



OPERATION FOR APPENDICITIS. 



447 



edge of the rectus, and under the other, the transversalis (Fig. 334)- 
Split the sheath of the rectus and retract the edge of the rectus 
exposing the transversahs fascia. 

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Fig. 336. — Appendix and part of cecum delivered and walled off with gauze. 

and pick up a fold of the peritoneum, and divide it, turning the cutting 
edge of the knife away from the abdomen (Fig. 335). Usually the great 
omentum will bulge into the wound after the peritoneal incision is 
enlarged. Replace the omentum and, if necessary, hold it with a 
gauze pad. 



448 



APPENDICITIS. PURULENT PERITONITIS. 



Next introduce a finger and feel for the cecum, which will be 
recognized by its bands, and pull it up into the wound until the base 
of the appendix can be seen. The appendix may be adherent, and 
the adhesions should be broken up very gently. Once the appendix 



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Fig. 337. — Peritoneal cufE turned back; appendix ligated and amputated. 

is freed, it is to be brought up out of the wound and the cecum re- 
turned to the abdominal cavity and walled off with gauze pads (Fig. 

Tie off the meso-appendix with catgut and cut it away from the 
appendix close to its line of attachment. 



OPERATION FOR APPENDICEAL ABSCESS. 



449 



An incision is now carried around the base of the appendix, dividing 
only the serous coat, which is stripped back toward the cecum, 
forming a peritoneal cuff (Fig. 337). The appendix is now ligated 
and cut off, the mucous stump touched with carbolic acid and then 
with alcohol. The peritoneal cuff is drawn over the stump and sutured. 
The stump is now invaginated and buried with a row of Lembert 
sutures. The gauze pads are removed with the exception of one, 
which covers the cecum until the last stitches are placed in the peri- 
toneum. Repair by separate lines of suture, the peritoneum, trans- 
versalis, aponeurosis and skin. Drainage is unnecessary. 

B. The incision, four inches long, is a finger's breadth to the inside 
of the anterior superior iliac spine, with its middle corresponding to 
the spine (Fig. 338). 

The first incision traverses the skin and superficial fascia, which 





Fbg. 338. — Appendiceal incision. (Veau.) 




Fig. 339. — The external oblique dix-ided; 
the internal oblique exposed. (Veau.) 



are likely to be very vascular in such a case. The external oblique 
appears, its fibers parallel with the incision. Divide it the whole 
length of the wound and catch the edges with forceps which will serve 
as retractors (Fig. 339). 

Next divide the internal oblique and transversalis muscles, whose 
29 



450 



APPENDICITIS. PURULENT PERITONITIS. 



fibers run transversely. The layer is thick, and several vessels will 
need to be caught (Fig. 340). 

Retract these layers and the transversalis fascia is exposed. This 
you divide, bringing into view the peritoneum. If you do not expect 
complications, make the primary incision shorter, and split each 
muscular layer in the direction of its fibers. 

Catch up a fold with the forceps, and divide its base with the 
scissors (Fig. 341). From the small orifice thus created, there 
flows a sero- or purulent fluid. Enlarge the peritoneal opening and 




Fig. 340. — The two oblique muscles incised, 
the transversalis exposed. (Veau.) 



Pig. 341. — Showing the three muscular layers 
and the peritoneum incised. (Veau.) 



hold back the intestine with compresses. Examine the cavity. It 
may be that the omentum, thickened and infiltrated, will cover the 
field, but do not disturb it. 

Follow with the index finger the wall of the fossa until the cecum 
is reached. Wiping out the cavity, you may be able to see the bands 
of the cecum, which are to be followed downward by sight and touch, 
for they lead to the appendix. 

Remove the appendix if possible. You may not be able to find it 
but do not prolong the search and certainly do not break up adhesions 
in this search. 



OPERATION FOR APPENDICEA-L ABSCESS. 



451 



When it is located, gently draw it to the surface. It is exceedingly 
friable and should not be ruptured. Throw a catgut ligature about 
its base close up to the cecum and lie moderately tight (Fig. 342). 

Amputate the appendix and if there is no bleeding, cut the ligature 
short. Determine now the character of the suppuration, whether 
circumscribed or diffuse (Fig. 343). 

(a) // is Circumscribed. — Wipe out the cavity very carefully with 
sterile gauze. Do not irrigate. Place a drainage tube upward toward 
the diaphragm (Fig. 344). Do not use violence. There a new 




Fig, 342. — Throwing a_ligature around base of sloughing appendix. (Veau.) 



collection of pus may be found. Pass a second drainage tube in the 
same manner down into the pelvic cavity. This is the most important, 
for the fluids tend to collect there. Leave the third in the iliac fossa 
and the fourth directed toward the middle of the abdomen. Secure 
each with a safety pin (Fig. 345). Suture up to the drainage tubes, so 
that the opening will be only large enough to accommodate the tubes. 

If the patient is a female, after wiping out the cavity carefully, a 
counteropening may be made into the vagina in favorable cases, 
and with efficient drainage secured by that route, the abdomen may 
be completely closed. 



45^ 



APPENDICITIS. PURULENT PERITONITIS, 



• In many cases even without such drainage, the abdomen may be 
closed after cleansing the cavity, but it cannot be advised in the emerg- 
ency work of general practice. 

(b) The Suppuration is Di,^use.—Uurrkdly make an incision from 
the umbilicus downward for a couple of inches, which is sufi&cient. 
When the peritoneum is opened, the fingers can touch through the two 
openings. 




Fig. 343. — Diagram showing directions the pus may extend. A. Sub-hepatic; 
B. Pelvic. C. Iliac. (Veau.) 



If the pus seems to have reached into the left side, make a third 
incision over the left iliac fossa. Through these incisions irrigate 
the abdominal cavity with normal salt solution, using plenty, three 
or four quarts, and continue the irrigation until the fluid flows out 
clear. Unless it be complete, reaching every part of the cavity, 
irrigation had better be dispensed with. The additional incisions 
may even be unnecessary if the following treatment is pursued. 



SALINE ENEMA FOR DIFFUSE SUPPURATION. 



453 



The patient is now put in the Fowler position and a continuous 
rectal enema of normal salt solution arranged for. The purpose of 
this treatment, instituted by Murphy with such signal success, is to 
secure a constant saline lavage of the peritoneal cavity. In other 
words, the fluid passes from the bowel into the peritoneal cavity, 
accomplishes its healing mission and drains out through the ab- 
dominal wound. 

The fluid should be maintained at a temperature of joo° F., and 
should be allowed to flow into the rectum at the rate of one pint per 




Fig. 344. — Placing a tube in the sub-hepatic space. (Veau.) 



hour or thereabout. The patient's sensation should be consulted 
If there is a feeling of tightness and distress, the flow should be lessened. 
After two or three quarts have been introduced, the flow should be 
shut off for an hour or two. The injections may be continued one to 
three days. 

Moynihan reviews his experiences with this treatment (Lancet, 
Aug. 17, 1907) and concludes that it has exceptional value. He 
insists upon attention to the details of administration and describes 
the methods found most useful. The largest quantity of llie solution 
taken by any of his patients was sixteen pints for the hrsl twenty- 



454 APPENDICITIS. PURULENT PERITONITIS. 

four hours, and a total of twenty-nine pints in three days. He em- 
phasizes the character of improvement in the appearance of the 
patient, in his pulse and temperature, and in the action of kidneys 
and skin. 

The plan pursued by others aims to secure drainage by means of 
tubes passed in various directions into the intestinal mass and into 
the pelvic cavity. Under these circumstances, the enemas of normal 
salt solution should be used at intervals and the dressings changed 
on the second day. On the fifth day, the tubes should be removed, 
cleansed and replaced exactly as before. The patient must not strain 
while this change is being made and children may need to be given 
a few whiffs of chloroform. Cleanse the drainage tubes every third 
day, gradually shortening them as granulation proceeds. 

If a new focus of infection forms, if the temperature reaches beyond 
loi in the evening for two or three evenings, no matter what it was in 
the morning, one may be sure of suppuration somewhere. It will be 
necessary to reoperate and reestablish drainage. 

Septic peritonitis originating elsewhere than the appendix, ought 
to be similarly treated, but the results are so discouraging that the 
operation cannot be urged upon the general practitioner, however 
advisable it may be in hospital practice. 

The principle of treatment is the same. Make a median incision 
below the umbilicus and search for the cause. It may originate from 
a ruptured fallopian tube, it may follow perforation of the stomach 
or duodenum, and the break must be located and repaired. It may 
follow the perforation of typhoid fever and for this condition, the 
operation will be done more and more as time goes by. The present 
status of this procedure is probably fairly stated in the Pennsylvania 
Medical Journal, Feb. i, 1908: 

Hayes, of Pittsburg, reports a series of thirty-eight cases with four- 
teen recoveries (36.8 per cent). He operates under local anesthesia 
(cocaine J per cent.) and flushes the cavity with normal salt solution. 
He recommends that the perforated bowel be resected, regarding 
attempts at repair as futile. 

Mitchell, of Philadelphia, reporting on the experiences of the 
Pennsylvania Hospital, gives 23 per cent of recoveries. He recom- 



OPERATION FOR TYPHOID PERFORATION. 455 

mends opening through the outer border of the rectus muscle under 
ether anesthesia and with subsequent repair of the perforations. If 
too numerous, he advises packing off the injured portion of the bowel 
from the general cavity by gauze compresses. 

Laplace remarks that usually the surgeon is not called until the 
patient is in full shock and a general peritonitis is already begun 
He favors resection of the ulcer bearing area of the ileum. 

Douglass, of Nashville, reviews a long experience with purulent 
peritonitis and concludes (Med. Record, Feb. 23, 1902) that it is by 
no means always the same disease; that many factors, chiefly bacterio- 
logical, determine its onset, course and termination; that there is no 
one treatment, no method applicable to all cases ah'ke, no technique 
to be blindly accepted and followed to the exclusion of all others 



CHAPTER VIII. 
ACUTE INTESTINAL OBSTRUCTION. 

Acute occlusion of the intestinal canal is a condition always to be 
dreaded, for it begins suddenly and unexpectedly and, unless relieved, 
hurries to a fatal issue, due either to shock or sepsis. Fortunately, 
as Bloodgood says, the condition is not a frequent one, yet, none the 
less, it is an emergency whose character must be thoroughly under- 
stood. Walker, of Detroit, reviews his experience (American Journal 
of Surgery, December, 1906) and concludes that the mortality of the 
past (75 per cent) following operation for the relief of acute obstruc- 
tion, will be greatly diminished when the profession early diagnoses 
these cases and early submits them to operation. The responsibility 
falls chiefly upon the general practitioner. Nor can the condition be 
easily mistaken for something else, although less serious conditions 
may be mistaken for it. 

The group of symptoms constitutes a very definite clinical picture; 
(a) pain, (b) tympanites, (c) vomiting, (d) constipation, and (e) 
collapse. 

(a) The pain develops suddenly and severely, often following 
some violent exertion, and takes the form of paroxysmal colic. There 
is localized tenderness. 

(b) Tympanites is marked, the w^hole abdomen being distended, 
and often, on this account, the respiration and circulation are impaired. 
Peristalsis is exaggerated and the violent movements of the bowel 
may often be noted through the abdominal wall. At the site of the 
greatest tenderness, a tumor may be found. 

(c) There is often at first a rumbling of the bowels and nausea, 
soon followed by an incessant and distressing vomiting, at first gastric 
and finally fecal. 

(d) Constipation is a constant feature, though at first there may 
be some movement from the lower bowel. In intussusception there 

456 



DIAGNOSIS OF ACUTE OBSTRUCTION. 457 

is often all through the attack some discharge of bloody mucus and 
gas. This may be the case, too, in strangulation near the pylorus, but 
in such a case, the extreme distention of the stomach and the violence 
of its movements suggest the nature of the difficulty. 

(e) Collapse is imminent from the first and is indicated by the 
weak, thready pulse, the rapid breathing, the pale, pinched features, 
and the anxious expression. 

Sepsis may take the form of stercoremia and produce death early; 
or it may ensue later, subsequent to gangrene. 

These are the symptoms, whatever the form of the acute obstruc- 
tion, whether it be strangulation, intussusception, or volvulus, and 
very rarely can the form of the obstruction be definitely determined 
before the operation or posmortem. 

Certain factors make one of the conditions the most probable. If 
it is a child under ten years of age, it is almost certain to be intussus- 
ception; if there have been previous attacks of some form of peritonitis, 
strangulating bands of adhesion are likely to be present; if the patient 
is forty or fifty years of age, with a history of constipation, volvulus 
suggests itself. 

In addition to noting the symptoms and history, a careful search 
must always be made by palpation for an abdominal tumor, and 
finally the investigation is terminated by rectal or vaginal examination. 

Treatment. — In the few hours that must elapse before one can 
fully make up his mind that it is a case of acute obstruction, there are 
certain things to do, but, more especially, certain things not to do. 
Do not give purgatives. This is an axiom scarcely necessary to re- 
peat. They can do no good and will most certainly do harm. Do 
not give large and repeated doses of morphine. It will help the 
patient to die easy, but in such a case, it is ''not a remedy for the 
patient but a refuge for the doctor." It is doubtful even if it should be 
given at all. It is possible that minute doses may diminish the peris- 
talsis, quiet the vomiting to some extent, relieve the shock a little and 
ease the pain measurably without masking the true conditions, but 
under the circumstances, it is an edged tool. Give no nourishment 
by mouth. The two measures likely to be of the greatest benefit, 
are gastric lavage and rectal injections. 



45 8 ACUTE INTESTINAL OBSTRUCTION. 

The gastric lavage may in some measure diminish the vomiting 
and in case an anesthesia is necessary, it may prevent asphyxia from 
a gush of vomited matter. 

Rectal enemas are sometimes effective in relieving the obstruction, 
but if used, it must be with the strict proviso that the injection be done 
carefully. If roughly given, if the fluid is thrown into the bowel with 
too much force, even if there is no danger of rupturing the bowel, it 
at least irritates it and defeats its own purpose. 

There is a definite mode of procedure: put the patient crosswise in 
bed in the lithotomy position, with the pelvis turned slightly to the 
right side. Anoint the anal region well with vaseline, and also the 
rectal tube, which should be of soft rubber, three or four feet in length. 
In the case of an infant, a rubber catheter will serve. Guide the 
catheter with the left index finger and direct it as it enters the rectum, 
backward at first and then slightly to the left. Keep hold of the 
tube close up to the rectum, the better to control it. Push the tube a 
little at a time, and if it meets with the obstruction, withdraw it 
slightly, and advance it with a boring movement. Any force may 
result in the tube merely coiling up in the rectum, in the meantime 
the doctor having the impression that it is ascending high in the 
bowel. Sometimes it is advantageous to let the injection flow as 
soon as the first part of the tube is introduced, as by that means the 
rectum is dilated and Houston's valves are not so likely to intercept the 
tube. The tube must be introduced as high as possible without 
using force. 

Attach the fountain syringe, holding it low at first and gradually 
raising it to increase the pressure. It should not be raised much 
more than three feet above the patient's level. The quantity of 
fluid, either warm salt solution or oil, which may be injected, varies 
with the age, say one pint for the infant and four to six quarts for 
the adult. 

When the injection is completed, withdraw the tube rapidly, and 
lay the patient back in bed. The enema will be expelled sooner or 
later with severe colicy pains. If ineffective, it returns practically 
clear. If it has done good, it will be accompanied by flatus, and 
at the last, there will be some hard lumps. The final evacuation may 



ARTIFICIAL ANUS FOR ACUTE OBSTRUCTION. 459 

not take place for some time, but the escape of gas is a good indication 
that the obstruction has been at least temporarily relieved. 

Lejars recommends the "electric bath" as efficacious in many cases, 
but this treatment is scarcely applicable in general practice. 

On the whole, the treatment is surgical and the doctor must have 
it on his conscience that if the case is acute obstruction, delay is dan- 
gerous or even fatal. The point is to make the diagnosis quickly, 
and when that is made, there is only one thing to do, operate. 

The practitioner will hesitate between two procedures, median 
laparotomy and artificial anus. 

Median laparotomy is the ideal operation. It, only, is curative, for 
the cause of the obstruction is found and relieved, but it is delicate and 
dangerous. These are the conditions which 
Veau formulates, under which alone the 
doctor must undertake it: 

(a) The operator must be experienced 
and resourceful, for it is often difficult to 
locate the cause and equally difficult to 
remove it, and the distended bowel is 
always a source of embarrassment. 

(b) The operation must be conducted 

, ^, ,1 . 1 . , Fig. 345. — Intussusception. 

where there are the surgical accessories and (Waisham.) 

capable assistants. 

(c) The diagnosis must have be^ perfected, so that the operator 
knows about what he will have to do. 

(d) The patient must be vigorous and able to stand a tedious and 
prolonged operation. 

These conditions are nearly always lacking when the doctor is thrown 
absolutely upon his own resources, so it may be laid down as a rule 
that the general practitioner must choose the second procedure. 

An artificial anus will usually save the patient's life and is within 
the skill of any doctor under almost any circumstance. After the 
patient has later regained his strength, the operation necessary to 
complete a cure may be undertaken. It will not be an emergency 
operation and the time and place may be chosen. 

To make a temporary artificial anus will be the proper procedure 




460 ACUTE INTESTINAL OBSTRUCTION. 

under the circumstances indicated. There is a single notable ex- 
ception: if the patient is a child with an undoubted attack of intussus- 
ception, it is imperative to do a laparotomy if the enemas have failed 
to give relief (Fig. 345). 

OPERATION FOR INTUSSUSCEPTION. 

A case reported by Estes (American Journal of Surgery, August, 
1906) illustrates the subject. 

A girl of three years in fair health, three days before had been seized 
with violent abdominal pains with straining and tenesmus. At 
first the passages were fecal and then mucus, tinged with blood. She 
had intervals of apparent ease when she would play with her toys and 
ask for something to eat. After three days' treatment by enemas and 
light laxatives, she developed signs of complete obstruction. The 
abdomen was distended, vomiting frequent and at last feculent; there 
was persistent pain, rapid, weak pulse, and general weakness. At 
this time Estes was called and "found a very pale, emaciated, weak, 
suffering baby, with pulse 130, and temperature loi. She was 
vomiting every half hour. No distinct tumor could be felt, but there 
was some thickening in the right iliac region. Through that night, 
while preparing for the operation next morning, she was given some 
strychnia and morphia and saline enemas, which produced an im- 
provement. 

Operation — median incision. A hand passed into the right iliac 
foss;t located the sausage-shaped tumor of an ileo-cecal intussuscep- 
tion. Turning the child to get the intestines out of the way, gentle 
milking motions were made and almost immediately the intussuscep- 
tion was reduced. Inspection showed a very much thickened and 
inflamed section of the ileum about six inches long. It was decided 
not to exsect the injured gul. The torn border of the mesentery was 
sutured, the peritoneal coat bathed wdth hot saline solution, dried, 
sprinkled with aristol and replaced, and the abdomen rapidly closed. 
The child made a rapid and uninterrupted recovery and has been 
quite well ever since. 

The principle steps in the operation are as follow\s: 

(t) Median laparotomy. Be careful in opening the peritoneum 



senn's method of disinvagination. 



461 



not to wound the distended bowel. Expect to find trouble in the 
management of the bowel. A skillful assistant is a great comfort in 
this matter. 

(2) Search jor the obstruction. The obstruction is usually easily 
found in intussusception. After the abdomen is opened, proceed 
directly to the right iliac fossa, having no fear to introduce the whole 
hand, if gently done. In any case the cecum is first to be examined, 




Fig. 346. — Senn's method of performing taxis in reduciug an invagination. 



for by its condition, one can determine whether the obstruction is in 
the large or small intestine. 

The sausage-shaped tumor (in the case of intussusception) is 
pulled up into the wound and its topography carefully noted and its 
integrity determined. If there are no adhesions, if there are no 
appearances of gangrene, in other words, if the accident is recent, 
try to reduce the bowel. 

(3) Disinvaginate, following the procedure of Senn, which has 
for its aim first to reduce the edema. This is to be accomplished by 
steady and uninterrupted manual compression of the tumor. 



462 



ACUTE INTESTINAL OBSTRUCTION. 



As soon as the swelling is reduced, grasp the bowel below the tumor 
and press gently but firmly against the apex of the intussusceptum, 
at the same time making easy traction at the other end (Fig. 346). Re- 
member it is easy to tear the bowel or mesentery. 

When the bowel is reduced, examine again for gangrene. If 
there are points of disintegration, cover them in by Lembert sutures. 
If the whole segment of the bowel is gangrenous, it must be resected; 
or if doubtful, retained in the wound for further inspection. If the 

bowel is not impaired, wash and re- 
turn; and the operation is completed 
by the repair of the abdominal wall. 
If, as Senn says, repeated attempts 
at reduction fail, one of two courses 
must be pursued: the establishment 
of an intestinal anastomosis, or resec- 
tion of the invaginated portion; but the 
latter, on account of the time required, 
must not be undertaken unless the 
invaginated parts are gangrenous. 

The anastomosis between the parts 
of the bowel above and below the 
invagination may be accomplished by 
suture or the Murphy button. The 
technique of resection of the invagi- 
nated portion is represented in Figures 
347, 348, 349, and 350. 
A case reported by Edmund Clark, of Indianapolis, in a way typifies 
the condition and emphasizes the points which serve to distinguish 
intussusception from other forms of obstruction (Ind. Med. Jour. 
March, 1908), The patient, nine months old, previously well, began 
to have fits of crying. In a few hours, it began to have frequent bowel 
movements which contained blood and mucus. A sausage-shaped 
tumor was discovered. On the second day the child was brought 
to Clark and its appearance was such as to suggest there was nothing 
serious the matter with it. But such appearances may be deceptive. 
An examination demonstrated the necessity for operation. 




Fig. 347- 



-Intussusceptum exposed. 
(Guibe.) 



OPERATION FOR OBSTRUCTION. CLARK. 



463 



By means of a median incision two and one-half inches long, the 
tumor in the right iliac region was reached and delivered. Three 
feet of the ileum with its mesentery was found in the cecum. The 
mass was dark red but not gangrenous. Though tightly constricted, 
it was disinvaginated without difficulty. The abdomen was closed 
without drainage; the whole operation lasted fifteen minutes. Re- 
covery was complete. 

The predisposing cause of such attacks is often acute indigestion. 




Fig. 348. — Intussusceptum resected. (Guibe.) 



The pain, which is the first symptom, is often merely colicky at 
first, but later may be persistent. Vomiting is common bnt nearly 
so severe as in other forms of obstruction, nor does it appear so early. 
The temporary relief following the vomiting is characteristic of in- 
tussusception. The nearer the duodenum the invagination is situated, 
the more severe the vomitus. Rigidity is not an early symptom 
Distention is absent until late. Tenderness is also a late symptom 
indeed, in the early stages, pressure may give relief. 

The presence of a tumor is of great diagnostic value; it is usually 
movable, hard and resistant. Its size gives no idea of the amount of 



464 



ACUTE INTESTINAL OBSTRUCTION. 



bowel involved. Tenderness is a severe and early symptom; thirst not 
marked. 

Clark says, regarding the indications for operation, that well- 
established lines of treatment, if simple and non-operative, die hard, 
so that medical treatment of such cases will only be given up after 
many more lives are sacrificed and many more cases successfully treated 
by laparotomy reported. 





Fig. 349- 



-Anastomosis after resection. 
(Guibe.) 



Fig. 350. — Repair of the bowel and 
application of Lembert sutures over 
the site of anastomosis. (Guibe.) 



CHAPTER IX. 

ARTIFICIAL ANUS: TEMPORARY; PERMANENT. 

TEMPORARY ARTIFICIAL ANUS— ENTEROSTOMY. 

An acute obstruction of the bowel may necessitate a temporary 
drainage through the abdominal wall. This will be the case when 
circumstances such as environment, lack of experience, assistance or 
equipment preclude a laparotomy; or even when a laparotomy is 
done and it is found impossible at the time to remove the cause. 

Enterostomy- is therefore a life-saving operation which every practi- 
tioner must know how^ to perform. 

The operation proposes opening the abdomen, anchoring a loop of 
intestine in the abdominal wound and opening this loop to secure 
drainage. The incision will be made ordinarily in the right iliac 
fossa and the opening in the bowel made above the obstruction. 
For that matter, one need scarcely fear that he will open into the bowel 
below the constriction, for it is only the distended portion that wall 
present. It is preferable to open the cecum but if it is not available, 
whatever loop presents will do. 

No special instruments are required. It is a good idea to have 
several needles already threaded with silk No. o or No. i. Local 
anesthesia may suffice. 

Incision. — Begin by dividing the skin and fat along a line two 
fingers' breadth from the anterior superior iliac spine, parallel with 
the fibers of the external oblique — an incision about three inches long, 
whose central point corresponds to the anterior superior iliac spine 
(Fig. 351). Catch up the two or three bleeding points. 

This first incision exposes the external oblique (Fig, 336) and the 

second divides that muscle in the same line. Catch up the edges 

of the divided muscle. In the same manner, the third incision divides 

the internal oblique and transversalis, and finally exposes a fibrous 

30 465 



466 



ARTIFICIAL anus: TEMPOEARY; PERMANENT. 



layer, the transversalis fascia, which is carefully divided in order to 
reach the peritoneum (Fig. 337). Pick up a fold of that membrane with 
the dissecting forceps and divide it at the base, remembering that the 
distended bowel is in close contact (Fig. 338). 

A reddish fluid escapes as soon as the peritoneum is opened; seize 
each lip with forceps and enlarge the opening, but not to the full extent 
of the skin wound. Restrain the bulging gut with compresses. In- 
troduce the index finger and examine in various directions for a source 

) 





Fig. 3SI. — Trace of incisions for artificial Fig. 352. 
anus: on the right, temporary; on the left, 
permanent. (Veau.) 



-Locating the coecum. (Veau.) 



of obstruction. Happily it may be found and relieved without loss 
of time. Usually, however, it will not be and one must not persist in 
his search or effort at relief. Attempt next to locate the cecum, pass- 
ing the index finger down into the iliac fossa, following the external 
wall (Fig. 352). 

If successful in locating it, pull it up into the wound with index 
finger and thumb and hold it with two artery forceps. It is easily 
identified by the appendices epiploicae and by its bands. If the ce- 
cum cannot be reached, employ any loop which presents. 

Anchor the boweL The bowel is sutured to the abdominal wall 



MODE OF ANCHORING THE BOWEL. 



467 



in this manner: Commence at one angle passing the needle through 
the parietal peritoneum of one side, through the serous and muscular 





Fig. 353. — Attaching the bowel in the Fig. 544. — Attaching the bowel laterally, 

angle of the wound. (Veau.) (Veau.) 




Fig. 355. — Diagram showing 
disposition of suture. (Veau.) 




Fig. 3-^ 6. — Opening of the bowel with thermo- 
cautery. (Veau.) 



coats of the bowel and through the peritoneum of the opposite side. 
Tie, but do not cut the threads (Fig. 353). Now make on each side three 
or four ''U" sutures one-half inch apart in this manner: the needle 



468 



ARTIFICIAL anus: TEMPORARY; PERMANENT. 



passes through the parietal peritoneum, the mucous and muscular 
coats of the bowel and out through the parietal peritoneum of the 
same side. Do the same on the opposite side (Fig. 354). Collect the 
loose ends of the sutures of the same kind in one forceps. In placing 
the sutures, do not let the protruding segment of bowel get folded or 
wrinkled. 

Suture the remaining angle in the same manner as the first and 
complete the repair of the peritoneal wound. The loop of bowel 





Fig. 357. — Temporary arti- 
ficial anus. (Veau.) 



Fig. 358. — Incisions for temporary and 
permanent artificial anus. (Veau.) 



may not occupy all of it and these peritoneal sutures are cut short at 
once, (The relative position of the sutures is represented in Figure 

355-) 

Now repair the superficial w^ound by interrupted sutures in two 
layers, one reuniting the muscles; the other, the skin. The opening 
left immediately over the anchored gut is about an inch in length. 
Cut the threads short. 

Open the bowel. This is reserved for the last, and here the long 
threads of the lateral bowel suture, left until this time, are used to 
pull the bowel well into view (Fig. 356). Incise it with the bistoury 
for about an inch and there is an immediate escape of gas. 

Cut short all the sutures. The bowel will not immediately empty 



OPERATION FOR PERMANENT ARTIFICIAL ANUS. 



469 



itself. It will require possibly twenty-four hours, during which time 
the dressing should be changed every half hour, after which time twice 
daily is sufficient. 

Remove the cutaneous sutures on the sixth day, else later they will 
become septic. Apply ointments to the inflamed skin. 

When the bowel is once emptied, which may require as long as twenty 
four hours, seek to locate the site of the obstruction and to determine 




Fig. 359. — Opening the peritoneum. (Guibe.) 

its nature. See if an enema will find exit at the wound or if an in- 
jection at the wound will discharge per anum (Fig. 357). A month 
later when the patient has regained his strength, if the bowel has not 
become normal, send him to a specialist. 



PERMANENT ARTIFICIAL ANUS. 

This operation, palliative in the treatment of cancer of the rectum, 
comes within the scope of every doctor. It may even be regarded as 
an emergency. There may come a time in the history of the case 



470 



ARTIFICIAL anus: TEMPORARY; PERMANENT. 



when the content of the bowel can no longer pass and the pain is un- 
bearable. Then the operation will give great relief. The patient 




Fig. 360. — The sigmoid flexure drawn out through the incision. Note the 
appendices epiploicae. (Veau.) 




Fig. 361. — A Forceps used to make an opening in the mesentery. (Veau.) 

suffers little pain after the operation, gains in weight, believes that he 
is going to get well and so dies happy. 



INCISION FOR PERMANENT ARTIFICAL ANUS. 



471 



In this case, the opening is to be in the sigmoid; it may need to be 
large. The bowel is completely divided transversely and the two ends 
anchored separately in the wound. 

The operation is best done in two stages. In the first, the sigmoid 




Fig. 362. — Bowel retained by strip of iodotorm gauze. (Veau.) 

is drawn out and permitted to acquire adhesions. Subsequently the 
loop is resected. 

First Stage. — An incision two inches in length is made obliquely 
over the left iliac fossa, a couple of fingers' breadth within the an- 
terior superior spine. The lower end of the incision reaches to just 
above the level of the spine (Fig. 358). Dividing the skin and cellular 
tissue, there will be some small vessels to ligate. The fibers of the 




Fig. 363. — Dividing the loop with the thermocautery. (Veau.) 

external oblique appear, running parallel with the incision. Separate 
them in the line and length of the skin incision by blunt dissection. 
Widely separate the two portions of the muscle with retractors. 

In the bottom of the wound are seen the fibers of the internal oblique 
and transversalis which lie at right angles to the external oblique. 



472 



ARTIFICIAL anus: TEMPORARY; PERMANENT. 



Open through them by blunt dissection in the direction of their fibers 
and retract (Fig. 347). 

Divide the transversalis fascia and expose the peritoneum. This 
is opened and its lips seized with the forceps. Remove the retractors. 

Search jor the sigmoid. Introduce the index finger into the iliac 
fossa, following the posterior wall until arrested by the meso-sigmoid. 
In this manner locate the sigmoid flexure, and with finger and thumb 
draw it to the surface by gentle but persistent traction. It can be 





Fig. 364. — Upper ori- 
fice communicates with 
bowel ; lower with rec- 
tum. (Veau.) 



Fig. 365. — Permanent arti- 
ficial anus. External opening 
of bowel with spur leading to 
rectum. (Veau.) 



felt to yield. Once the loop is exposed, the only difficulty is overcome. 
The sigmoid is identified by the appendices epiploicae (Fig. 360). 

Spread out the gut and find the least vascular part of the exposed 
mesentery and this part transfix (Fig. 361) with a closed forceps. 
Withdrawing the forceps, seize a roll of iodoform gauze of the caliber 
of the index finger and draw it into place. It will hold the bowel in 
position (Fig. 362). , \/ 

If the cutaneous wound is too large and does not fit closely to the 
projecting loop, it may be diminished by a suture or two. ' [ ' 

Dress with sterile gauze and do not change until ready to resect. 



PERMANENT ARTIFICIAL ANUS. 473 

unless the dressing becomes loosened or soiled. Keep the patient 
on a light diet, chiefly milk. 

Second Stage. — Resect the bowel. On the second or third day, 
when the bowel has acquired adhesions, return with a thermo-cautery 
and artery forceps; there might be an arteriole to ligate. No anesthe- 
sia is necessary, for the gut is quite insensitive. 

The thermo-cautery is heated to a dark red (if at a white heat, 
there may be a little bleeding) and with it the bowel is completely 
divided. Do not stop until the roll of iodoform gauze is completely 
exposed. The few minutes required will necessarily seem a long time, 
but do not get disturbed (Fig. 363). When the section is complete, 
the gauze may be readily removed (Veau). 

Apply a dry dressing. On the second day give a laxative. After 
a while the patient will be able to regulate his passages to a degree. 

Through the lower orifice the cancer may be douched and the fluids 
will find their way out per anum (Fig. 364, 365). 

Do not neglect to warn the family that the end must come within 
from eight to fifteen months. As for the patient, it were better to 
ease his mind by vague references to the future closure of the wound, 
so repulsive to him. 



CHAPTER X. 
STRANGULATED HERNIA. 

What doctor in general practice has not had his experiences with 
strangulated hernia? And how many have escaped the conviction 
that it is an emergency deserving its evil fame? 

But after all, its sinister reputation our predecessors have bequeathed 
us and, along with it, interminable discussions touching the agent of 
constriction and the indications for taxis. 

Today we reverently lay aside those old notions, for we know 
that no other equally dangerous condition yields better results to appro- 
priate treatment. By ''appropriate treatment" is meant early opera- 
tion. The indications for operation there is no need to discuss for 
operation is always indicated. 

Taxis is an exceptional procedure, permissible only as a tenta- 
tive measure under certain well-defined restrictions ; and even then to 
be used with fear, for who can certainly tell that he has not reduced a 
gangrenous and perforated gut; and who but the most experienced 
may not be misled by certain forms of incomplete reduction. 

The danger from strangulated hernia was formerly supposed to 
arise solely from interference with the circulation and the consequent 
gangrene of the incarcerated loop, and the attention was centered 
chiefly upon the mechanical element. It was perhaps legitimate 
upon that hypothesis to treat expectantly, or by repeated efforts at 
taxis, an incompletely strangulated hernia. 

But now it is definitely determined that the chief source of danger is 
septic absorption, and in a given case long before the incarcerated 
bowel has ceased to be viable, the patient may be overwhelmed by 
toxins of a virulent type. It is this systemic poisoning that makes 
strangulated hernia dangerous, and which especially makes the opera- 
tion dangerous. It is for that reason that procrastination is so often 
fatal. So frequently it happens with these attacks that after hours of 

474 



DIAGNOSIS OF STRANGULATED HERNIA, 475 

waiting, or after repeated efforts at reduction, the patient is finally 
turned over to the operator; and though the operation be of short 
duration and simple, yet the patient dies, for the reason that his 
powers of resistance were paralyzed by sepsis unsuspected. He was 
a veritable victim of delay. 

The thought to be kept uppermost, then, in treating strangulated 
hernia is not so much that the bowel is becoming gangrenous as that 
sepsis is imminent. 

The diagnosis is not difficult as a rule. Usually the patient is 
known to have a hernia ; suddenly it becomes painful and irreducible ; 
the bowels refuse to move and become tympanitic; nausea and vomit- 
ing ensue; and there are signs of circulatory depression. The general 
symptoms are in fact those of intestinal obstruction. The face is 
drawn and pinched, the lips white and the eyes sunken. There is a 
clammy sweat. The symptoms may all be mild at first, especially 
when the obstruction is not complete, or in the aged or debilitated, or 
if the bowel is surrounded by omentum which at first bears the brunt 
of the compression. It must be kept in mind that this mild onset may 
be wholly deceptive. 

It may be necessary to distinguish between an inflamed and ob- 
structed irreducible hernia on the one hand and strangulated hernia 
upon the other; in the first, pain and vomiting are not so severe, there is 
no collapse, and an impulse in coughing can always be detected. If a 
hernia was not before suspected a careful examination for one must 
be made in cases of intestinal obstruction. Small sciatic or obturator 
herniae are easily overlooked. This is likewise true of small femoral 
hernia in fat subjects. 

Torsion of the spermatic cord or strangulation of an undescended 
testicle may simulate strangulated hernia, but the indurated and very 
painful inguinal tumor, together with the cryptorchism, should suggest 
the nature of the attack. 

As Senn says, the differential diagnosis between a suppurative 
lymphadenitis in the groin and a strangulated inguinal hernia may be 
very difi&cult. He points out the necessity for caution in using the 
knife if the inflammatory swelling is single and occupies the site of 
a femoral hernia. In such a case the supposed gland should be ap- 



476 STRANGULATED HERNIA. 

proached by a careful dissection. If it proves to be a hernia no harm 
is done. 

An accumulation of peritoneal fluid in the imperfectly closed 
processus vaginalis in the very young may give rise to symptoms of 
strangulation,- but strangulated hernia is rare in infants. In such 
a case inversion of the patient for a few minutes will empty the sac 
and clear up the diagnosis. 

As has been said the indication for treatment is operation as soon as 
the diagnosis is made. There are, however, exceptional instances 
in which judicious efforts at taxis may be applied without greatly 
prejudicing the prognosis. But it is recommended without enthu- 
siasm and only out of due respect to those circumstances of time 
and place which seem to preclude immediate herniotomy. 

Taxis and operation, then, represent the sole measures of relief. 
Certainly no doctor at the present time would expect anything but 
harm from the use of drugs. 

As Senn says (Practical Surgery), no modern physician would for 
a moment consider seriously the therapeutic value of nauseating 
enemata, or the internal use of relaxing antispasmodic remedies, so 
much relied upon in facilitating taxis before herniotomy was shorn 
of its great mortality by the introduction of antiseptic surgery. 

Taxis. — Taxis, or the reduction of a hernia by methodical manipu- 
lation without instruments, is permissible only under these circum- 
stances: (a) The case is seen soon after the strangulation began; 
the hernia is of moderate size; the abdominal symptoms are not 
severe. 

(b) The patient is an old man debilitated, manifestly a poor sub- 
ject for an operation; he has had trouble before; it is only a few hours 
since his hernia became irreducible. 

Under these circumstances use taxis and it will not be dangerous 
if properly applied and not repeated. The further proviso must be 
made that if it fails an immediate operation must be done. In the 
milder cases Senn advises that taxis may sometimes be facilitated by 
administering a dose of opium and giving a high enema. A full hot 
bath in many instances has an excellent effect. 

In the severer cases a general anesthesia is always required. Before 



TAXIS FOR INGUINAL HERNIA. 477 

beginning the anesthesia prepare' the patient for operation so that 
if taxis fails no time need be lost and a single anesthesia will serve 
both for the taxis and the operation. Chloroform is usually preferable 
to ether if it is expected that taxis will succeed. It permits a greater 
relaxation. 

Technique of Taxis: Inguinal Hernia. — Elevate the hips, flex 
and separate the thighs in order to relax the external ring. Grasp 
the tumor with the right hand (hernia on right side) so as to com- 
press it uniformly with the tips of the fingers and thumb. Seize the 
neck at the external ring between the thumb and forefinger of the 
left hand. While the right gently compresses the tumor, the left 
empties the gut by stripping in the direction of the external ring at 
first, and later along the inguinal canal. The sole aim of this first 
manoeuvre is to empty the gut. The manipulations must be made 
methodically, without interruption and without force. If compres- 
sion reveals the presence of a doughy mass it is omentum, and as 
it probably occupies the lower part of the sac it will be better to 
compress nearer the neck in order to deal more directly with the 
intestine. Sometimes, to make traction on the tumor while the fingers 
at the neck continue the kneading will start the bowel contents to- 
ward the abdominal cavity. If the tumor under these manipulations 
grows smaller and softer, it is some guarantee of success. When the 
bowel is suflSciently emptied, it then becomes reducible and its return 
to the abdominal cavity is announced by a gurgling or a marked sense 
of yielding. 

When the bowel is reduced, the omentum, if present, should be 
returned in the same manner. One should not persist if the mass 
is thick and adherent for there is risk of rupture of an omental vessel, 
which may be followed by hemorrhage, all the more grave because 
unperceived. 

After the hernia is reduced the patient must be put to bed and 
no food by mouth permitted for at least 24 hours. Before getting 
about a tiuss must be fitted. 

If after ten or fifteen minutes of gentle effort the hernial tumor 
remains unchanged in size and hardness, it is a waste of time to 
prolong the procedure. It cannot be said too often that repeated at- 



478 



STRANGULATED HERNIA. 



tempts are injurious, becoming with each repetition more and more 
harmful and illusory. 

It may happen that after the hernia has been apparently reduced 
the symptoms oj obstruction still persist, or even if at first relieved, 
appear again. The tympanites augments, the nausea and vomiting 
continue and the signs of sepsis progress. It is evident that something 
is amiss. One of several things may have happened, but no time is to 
be wasted in conjecture, for only the operation which must follow will 
definitely clear up the doubi. 



.iWfe ^:mh 



HI 



/ 



%-. 



,w 




Fig. 366. — Strangulated hernia reduced] 
" enmasse." (Moullin.) 



Fig. 367. — Incomplete reduction 
of strangulated loop. Hernia in a 
diverticulum. (Movillin.) 



It may be that the hernial tumor has been reduced en masse. 
The hernial sac and it? contents have been carried through the ex- 
ternal ring without having changed their relations and the constriction 
persists (Fig. 366). This can occur in recent hernia in which the sac 
is not adherent and is most common in the direct form ot inguinal 
hernia. 

It may be that instead of entering the peritoneal cavity the herniated 
loop has entered a diverticulum of the sac near the neck and there 
becomes once more strangulated (Fig. 367). 

It may be that the neck of the sac has torn loose from the rest of 
the sac and has been reduced with the gut, the strangulation still being 
maintained (Fig. 368.). 



OPERATION FOR STRANGULATED INGUINAL HERNIA. 



479 



- - D 



Again, a rent may be torn in the sac and the gut escaping therefrom 
pushes up between the peritoneum and the abdominal wall (Fig. 369). 

Finally the reduction may have been complete, but the gut was 
gangrenous or ruptured and a gener.al peritonitis follows, due to the 
escape of the intestinal contents; 
or the peritonitis may even be 
due to the infection from the 
septic fluids in the sac. 

Femoral and Umbilical Her- 
nia. — These forms of strangu- 
lated hernia requiie the same 
mode of procedure as the in- 
guinal but are likely to present 
more obstacles. In the case of 
femoial hernia, if complete, the 
pressure must be made down- 
ward toward the saphenous 
opening at first, and then up- 
ward along the femoral canal. 

In the case of umbilical hernia 
the pressure must be 'made 
toward the umbilical ring. 
Often the Trendelenburg posi- 
tion is helpful. The constant 
effort is first to empty the gut 
and then reduce it. 

In both these forms of hernia 
the gut may be enveloped by a 

mass of omentum which may not be reducible and thus gives rise to 
some doubt whether the gut has been reduced. 

Operation for Strangulated Hernia: Inguinal Hernia. — To re- 
peat, as soon as a hernia habitually reducible becomes painful and 
irreducible and is accompanied by the signs of beginning prostration, 
regard it as strangulated, and, aside fiom the exceptional cases in- 
dicated, operate at once. Do not wait for fecal vomiting for that is 
the last signal of exhausted nature — the precursor of death. 




Fig. 368. — Strangulated hernia reduced "en 
masse." A. Upper end of the loop. B. Neck 
of the sac torn ofE and reduced with the bowel. 
C. Reduced loop still strangulated. D. Scrotal 
portion of sac. (Lejars.) 



48o 



STRANGULATED HERNIA. 



General anesthesia is usually necessary^ although in some cases of 
profound sepsis local anesthesia with cocaine or stovaine suffices, 
using Schleich's formula and injecting the various layers just before 
dividing. No special instruments are necessary. 

Surgical Anatomy. — The special points to be remembered are the 
situation of the abdominal rings, the relations of the external and 
internal oblique and transversalis muscles to the inguinal canal, and 
the location of the deep epigastric artery. 

The external ring in the aponeurosis of the external oblique lies 
just above the spine of the pubes. The internal ring in the trans- 
versalis fascia lies a half inch above 
\ the middle of Poupart's ligament. 

I '- ^ The deep epigastric artery passing 

vertically between the two rings lies 
between the transversalis fascia and 
the peritoneum. 

The chief condition of operating 
well is to see and recognize what is 
to be divided. The coverings enumer- 
ated with such care by the text-books 
will not be distinguished, but there is 
little danger of cutting into the intes- 
tine, for before it can be reached the 
sac must be opened, and that is an- 
nounced by the escape of a character- 
istic sero-sanguinous fluid. The greatest injury to the bowel is at the 
site of constriction, which may be at the external ring, the internal 
ring, or the neck of the sac. 

The preparation of the field of operation must be painstaking. 
The pelvis must be shaved and scrubbed; the adjacent abdominal and 
inguinal regions and the scrotum must be thoroughly disinfected; 
and the penis after cleansing wrapped in a sterile compress. 

First Step. Incision. Exposure of the Sac— Begin with a skin in- 
cision extending from the internal ling down to the spine of the pubes; 
if it is a sciotal hernia, down to the middle third of the scrotum 
(Fig. 370). Go directly through the skin and layers of fat to the 




Fig. 369. — Imperfect reduction by 
taxis. Hernia outside the ruptured 
sac. (Moullin.) 



EXPOSING THE SAC OF A STRANGULATED HERNIA. 481 

aponeurosis of the external oblique, dividing the branches of the 
superficial epigastric artery. 

Expose the aponeurosis thoroughly and incise it from one ring 
to the other. It is easily recognized by the oblique direction of its 
fibers and its shiny look. The lips of this wound should be caught up 
with forceps, especially at the external ring to serve later as a land- 
mark in beginning repair. 




Fig. 370. — Strangulated inguinal hernia; primary incision. 



Once the aponeurosis is opened the sac is exposed and the next 
effort is to isolate it preparatory to its incision. Separate it from 
the aponeurosis by careful blunt dissection around its whole circum- 
ference. Isolate the tumor up to the internal ring. If the sac is too 
intimately adherent to the aponeurosis it may be opened first. 

Second Step. Opening the Sac. — Catch a fold of the sac with dissecting 
j forceps and cautiously divide the base of this fold with scissors or 
[scalpel (Fig. 371). It may be one of the connective tissue coverings 
31 



482 STRANGULATED HERNIA. 

that is opened; divide it the full length of the wound and so proceed 
until finally the hernial sac itself is opened, which will be announced 
by a gush of bloody serum. Cautiously enlarge the opening till a 
finger can be introduced, and on it as a guide, split the sac close up to 
its neck (Fig. 372). When the constricting band is reached slip the 
finger under it, if possible, and divide it completely. If too tight for 
the finger, pass a grooved director as a guide. In some cases it may 
be better to use a herniotomy knife, but wherever possible avoid cut- 




^;^«^^ 



Pig. 371. — Opening the sac of a strangtilated hernia. As soon as the sac is 
opened a sero-sanguinous fluid escapes. (Guibe.) 



ting blindly. The constriction must be freely divided so that the 
intestine can be readily drawn down for inspection. This step is not 
complete till that is possible. 

It may happen that there is a second constricting band higher 
up; in such a case the forceps, w^hich should always be attached to the 
lips of the incision in the sac, are useful in pulling it down so that 
what is to be divided can be seen. 

Third Step. Examination oj the Intestine. — It is of the greatest im- 
portance that the site of the constriction be examined, for the chief 
lesions will be found there. Pull the gut down and observe the line 
of demarcation between the healthy and injured tissue (Fig. 373). 



TREATMENT OF THE STRANGULATED LOOP. 



483 



One of several conditions will be present and the line of procedure 
will depend upon the one which is found. 

I. The intestine is sound, that is to say, it has a uniform, dark 
violet color, most marked at the site of the constriction where it 
is lustrous. There is no erosion of the serous covering. Douching 




Fig. 372. — Dividing the constructing fibers of the stra.ngulated inguinal 
hernia. The parts should be well exposed. (Guibe.) 



the bowel with warm normal salt solution restores its tonicity, its 
rounded outline, and after a few minutes it assumes a redder color and 
is to be returned to the abdominal cavity. 

2. The intestine is slightly injured, that is to say, there may be 
several small zones of erosion exposing the muscular or even the 
mucous layer. Bury these areas with a few Lembert sutures, repair 
any injuries to the mesentery and reduce. If the intestinal loop is 



484 



STRANGULATED HERNIA. 



long, a methodical procedure may be required to pievent further in- 
jury to tissues already compromised. The posterior segment of the 
loop should be reduced first, as it probably was the last to come down; 
in the meantime the anterior segment must be carefully supported. 
The least rudeness may result in a tear. 

3. The intestine is doubtful, that is to say, it has a color mottled 




Fig. 373. — Examination of the strangulated loop. (Veau.) 



and gray and purple. It does not recover its form under the douch- 
ing but stays collapsed and flattened. Under these conditions it may 
not be possible to say whether it is gangrenous or not but it should 
not be reduced. 

Treves, however, advises reduction under these circumstances, 
remarking (Operative Surgery, p. 534, Vol. II) that whatever theoret- 
ical objections there may exist to this procedure, practice has shown 
that it may be safely carried out, assuming that this applies to a 



TREATMENT OF A GANGRENOUS LOOP. 485 

bowel which is not actually gangrenous, but in a condition which may 
be termed "doubtful." It is remarkable to what extent these doubt- 
ful intestines recover. The idea is that the peritoneal cavity is the 
most favorable site for recovery. 

If the operator is inexperienced and not certain that he can dis- 
tinguish between the bowel, possibly gangrenous, and that which has 
actually lost its viability, he must wait. Wrap the loop in moist gauze 
and after twelve hours examine again. It may be gangrenous or it may 
be viable, lustrous, reddened, rounded and impels the belief that it will 
become normal. With that belief, reduce it slowly and carefully, 
breaking up the slight adhesions which have already formed. 

4. The intestine is obviously gangrenous, that is to say, the serous 
coat has lost its luster, is blistered in spots and can easily be 
stripped off with the fingers; its color is ashen or even black, some- 
times mottled with white patches; there is a characteristic odor; the 
tissues are friable; and there may be perforations. 

In this case there is but one of two things to do: either anchor the 
gut in the wound and make an artificial anus; or resect the bowel. 

There can be no doubt that an enterectomy is the ideal procedure 
since it eliminates a source of danger and permits the radical cure 
of the hernia, but it is best not to undertake it unless skilled in intes- 
tinal suture (which for that matter every doctor should know thor- 
oughly how to do) for the time required may aggravate the shock 
and insure a fatality; but the first consideration is to save life. (See 
Enterectomy.) Allison, of Omaha (Jour. Minn. State Med. Assn., 
Jan., 1908), takes a different view: "we believe primary end to end 
anastomosis unjustifiable for, though we escape shock and peritonitis 
there yet remains the danger of permanent obstruction due to circu- 
latory and septic changes; or a fatal paralysis due to distention and 
toxemia. Artificial anus offers the best way oiit. The two stage 
operation is safer than the primary." 

If an artificial anus is considered safest pull enough of the gut out 
to reach sound tissue. Pass a catgut suture through the abdominal 
wall — that is through the aponeurosis and the parietal peritoneum — 
and then through the superficial coats of the bowel, then out through 
the abdominal wall again to make the letter "U." Employ four such 



486 STRANGULATED HERNIA. 

sutures at the cardinal points. To the gangrenous loop apply a moist 
antiseptic dressing, changed hourly if the intestine was perforated. 
If the intestine was not perforated, do not open it at once but wait a 
few hours till adhesions form. 

It is then to be opened and the dressings must be frequently changed 
for the discharge will be abundant. Later the fistula may gradually 
close of its own accord, more and more of the bowel contents passing 
by the rectum; or to cure the fistula a difficult operation may be 
necessary, (See temporary artificial anus.) 

Fourth Step. Ligation and Amputation oj the Sac. — In every case 
where the bowel may be returned to the peritoneal cavity, the treatment 
of the sac is of the greatest importance. After the intestine and omentum 
have been reduced proceed to dissect the sac if this has not already 
been done, remembering that the structures of the cord may be very 
intimately connected with it and hard to separate. The separating of 
the cord from the sac is often facilitated by stripping with the finger 
wrapped with gauze. When the sac is completely isolated the neck 
is to be freed quite into the abdominal cavity, and then a finger is to 
be passed into the opening, that any omental adhesions may be de- 
tected, or any concealed hemorrhage. Next, the sac is to be twisted 
and then ligated, or simply ligated as high up as possible, and 
amputated. 

In freeing the neck at the internal ring the subperitoneal fat is 
usually seen; at this stage the bladder may be injured, and the point 
is that any fatty tissues at the inner side of the ring must not be in- 
cluded in the ligature, for this fat may conceal the bladder. 

In ligating the sac it is best to transfix it rather than use the circular 
ligature. If the sac has been split so high that the neck cannot be 
defined, then the upper end of the peritoneal wound should be repaired 
with a few stitches so as to reconstruct the neck and then ligate. 

Fijth Step. — This will depend upon the condition of the patient. If 
his condition is serious, it is sufficient rapidly to reunite the aponeuro- 
sis and repair the skin incision. If a little more time may be used 
proceed to do the radical cure. Unless this is done recurrence is al- 
most certain, but the operator cannot be held responsible for that. 
In the urgent cases it is sufficient to have saved a life. 



AFTER-TREATMENT OF HERNIOTOMY. 487 

Whether the radical operation is attempted or not, employ drainage. 
The dressing must be carefully applied. 

Subsequent Treatment. — The patient must have no food for 24 hours. 
It may be necessary to employ salt solution freely. A little ice may be 
given to quench the thirst. At the end of 24 hours begin with small 
quantities of milk. Change the dressings the second day or sooner if 
much soiled. Remove the drain on the fifth. On the third or fourth 
day give a laxative. Remove the sutures on the eighth or ninth. 
Peritonitis may supervene if the gangrenous areas have not been 
properly treated. 

POSSIBLE COMPLICATIONS IN THE OPERATION. 

In the operation just described, the ordinary difficulties are indicated. 
But there are others, rarer, which may arise to disconcert the casual 
operator not forewarned. The actual operation is always easier if 
one has in mind all the possibilities. There may be unexpected ad- 
hesions; there may be anomalies with respect to the sac or its con- 
tents, or there may be unsuspected conditions produced by attempts 
at taxis. 

Adhesions must be anticipated when the hernia is large and has 
been for a long time irreducible, and under these circumstances 
special precautions must be taken not to wound the bowel in opening 
the sac. The adhesions if recent and soft may be broken up with 
the finger, or grooved director, keeping in close contact with the sac so 
as to avoid the bowel. 

If the adhesions are old and the union between the bowel or omen- 
tum with the sac firm and fibrous, it will be necessary to divide them 
with scalpel, or scissors, but this is a procedure requiring patience 
and a delicate touch. If necessary, long, band-like adhesions may be 
divided between forceps and subsequently ligated. 

If, following the decortication, the raw surfaces ooze to any serious 
extent, apply hot, moist compresses for a moment and either this 
will check the bleeding or at least reveal the site of the larger vessels 
to be caught up with forceps. Usually a few applications of the hot 
compresses will entirely suppress the oozing, or to a degree at least 
which will not contraindicate reduction, for when the bowel is no 



4o6 STRANGULATED HERXIA. 

longer bent and the circulation no longer interfered with the oozing 
will cease. 

But it is chiefly injury to the bow^el which is to be feared, not so 
much because the rent may be difficult to repair as that some of 
the septic contents of the bowel may escape. 

If the adhesions cannot he broken up the only thing left is to remove 
the source of the strangulation and leave the bowel outside. Occa- 
sionally it will be found that the source of strangulation is in some 
of the adhesions rather than the rings, or the neck of the sac; or again, 
so much scar tissue in the bowel wall leaves it inert and paralyzed. All 
these difficulties are more likely to occur in the neglected cases. 

A hernia of the cecum, or sigmoid, may present difficulties depend- 
ing upon adhesions. It must be remembered that these two portions 
of the large intestine are not completely invested by peritoneum, and in 
consequence it may come to pass that when they slide down through 
the inguinal canal a point is reached where a part of the bowel is out- 
side the hernial sac and this surface acquires adhesions to the scrotal 
tissues. In such cases these adhesions cannot be divided for fear 
of wounding important branches of the mesenteric arteries, so that 
to effect reduction a special procedure must be employed. 

In the first place, when on opening the hernial sac these parts 
of the large bowel are recogni/.ed, the neck of the hernia must be freely 
incised and the abdominal walls as well. In fact, one does what Lejars 
calls a hernio-laparotomy. 

Next the hernial sac is separated from the spermatic cord and 
then an effort is made to reduce the hernia en masse, returning, if 
possible, the bowel and the peritoneal prolongation at the same time. 
It will be a slow and tedious process. It is greatly aided by the 
Trendelenburg position. If the attempt fails an artificial anus is the 
last resort. 

Among the anomalies of the sac which may bother the operator 
are diverticula and double compartments. One may open into what 
appears to be the hernial sac and find it empty. In encysted hernia 
the processus vaginalis may be filled with fluid which surrounds the 
true hernial sac. A little study of the conditions will lead one to go 
ahead and find and open the true hernial sac. 



TREATMENT OF A HERNIATED BLADDER. 489 

The hernial sac may push in between the peritoneum and the 
muscular layers, bulging toward the iliac fossa or the bladder. This is 
the pro-peritoneal hernia and when it becomes strangulated, it is not 
likely a diagnosis wall be made. Yet the presence of a tumor in the 
inguinal region and the signs of intestinal obstruction will demand an 
operation and again a hernio-laparotomy is indicated. The site of 
strangulation is located and the bowel treated as in the ordinary form 
of strangulated hernia. 

In the interstitial form of hernia great difficulties may arise. The 
incision is likely to be quite different from the ordinary since it follows 
the long axis of the tumor. Once the hernial sac is exposed it must 
be freed from its adhesions to the muscles. The neck of the sac 
corresponds to the internal ring and if that is the site of constriction it 
must be divided by cutting outward. The deep epigastric artery lies to 
the inner side. 

After the bowel is reduced and the sac ligated, the break in the 
abdominal wall must be sutured, repairing the opening in each layer 
separately. 

The contents of the hernial sac may he abnormal. At some time 
or other each of the abdominal organs except the pancreas have been 
found herniated. It is the bladder which most often gives rise to 
trouble. 

It may be in the sac and appear as a second "sac" when the hernial 
sac is opened. It presents as a rounded, reddish tumor, perhaps as 
large as hen's egg. Such a tumor should never be opened on suspicion, 
but a careful effort must be made to locate its limits by blunt dissec- 
tion. The fact that it leads down to, and behind, the pubes clears up 
any doubt. It is to be reduced in the same manner as the intestine. 
In other instances it is without the sac, lying to the inner side of its 
neck and is perhaps intimately connected thereto. It may be mistaken 
for a thickened portion of the sac, or an adherent mass of fatty tissue. 

If it is opened into, the escape of urine and the evidence to the ex- 
amining finger of a large mucous lined cavity reveals the nature of the 
accident and imposes immediate repair. 

A large hernia easily reducible, or one whose size diminishes follow- 
ing urination or the use of the catheter suggests hernia of the bladder, 



490 STRANGULATED HERXIA. 

but unfortunately these signs are not available in strangulation. In 
every herniotomy the danger of wounding the bladder must be kept in 
mind. 

Another point Lejars makes: One may expose a thin walled trans- 
parent cyst at the inner side of the neck of the sac, and unwittingly 
open it only to find one's self working into the bladder. This trans- 
parent cyst, in no wise resembling the bladder, is due to a hernia of the 
mucosa of the bladder between the fibers of the muscularis. 

Following the separation of the bladder from the hernial sac the 
urine may be bloody for a day or two. This hematuria is of little 
moment and soon clears up. 

If the bladder is wounded its repair must precede everything 
else. As soon at the injury is discovered, pack around the site with 
sterile gauze, catch the edges of the wound with small forceps and 
suture, uniting the mucosa first with a continuous catgut suture, and 
the muscular coat with interrupted sutures, accurately applied; a third 
line connects the superficial tissues. 

The appendix may be found in the hernial sac, either inflamed or 
normal. If the latter it is to be removed in the ordinary way unless 
time presses, in which case one must be satisfied with reducing it. 

If the symptoms of strangulation arise in consequence of an in- 
flamed and herniated appendix, they may differ somewhat from those 
ordinarily observed. There will be the same tendency to collapse, the 
vomiting, the tympanites; but constipation may not be complete, and 
the hernial tumor in addition to being swollen and painful may be 
reddened and edematous. 

No one should think of taxis under these circumstances; an im- 
mediate operation is indicated. Regarding these grave cases, Kelly 
says (Vermiform AppendLx and its Diseases, p. 793) where there is 
suppuration in the sac it must be drained, and here as well as in the 
cases where there is gangrene in the appendix, resulting from strangu- 
lation, the utmost care must be observed in handling the diseased 
tissues in order to avoid inoculating the peritoneal ca\dty. If the dis- 
eased portion is found to extend up into the peritoneal ca^dty the 
operator must at all hazards discover the upper limits of the infection 
and resect the bowel in its healthy portion. 



TREATMENT OF A HERNIATED APPENDIX. 49 1 

Moreover, he must do this with the least possible manipulation 
and traction upon the parts, preferably by enlarging the abdominal 
opening in the direction of the inguinal canal while protecting the 
healthy regions and keeping the disease well isolated by abundant 
gauze compresses. 

When infection extends still further up into the abdomen an even 
wdder incision must be made, if necessary in the form of an inverted 
T in order to provide abundant drainage after removal of the disease. 
In such cases the cure of the hernia becomes a matter of secondary con- 
sideration to be taken up after recovery. 

McEwen (London Lancet, June i6, 1906) reports a case in which 
the patient, a man of 62, presented himself for an operation for strangu- 
lated hernia. Two weeks previously his hernia (of 12 years standing) 
had begun to give him pain, which had gradually increased. 

A large pyriform tumor occupied the right inguinal region and 
the scrotum, which was much inflamed. The mass was dull on per- 
cussion, there was no impulse on coughing and it was irreducible. 
On opening the sac the hernia was found to consist of the appendix, 
held in position by a pin protruding through its wall. There was no 
abscess formation, yet it was not deemed advisable after removal of 
the appendix to proceed with the radical cure. 

Regarding these unusual conditions, Lejars remarks that in be- 
ginning an operation for strangulated hernia we should expect every- 
thing and be surprised at nothing; laying aside for the moment all 
theoretical discussions and applying ourselves to the chief indication, 
not deeming our work complete until the bowel is properly reduced 
and lost to view in the abdominal cavity. 

Oliver, of Indianapolis (Ind. Med. Jour., March, 1908), reports a case 
in which the hernia had grown to remarkable proportions extending as 
low as the knee. The mass had long been irreducible. The patient 
was a butcher of about 50 years of age. Following a heavy meal of 
"pigs feet" and a lift, his hernia suddenly became painful and he ex- 
perienced the sensation of something giving way; symptoms of stran- 
gulation in mild form gradually developed; taxis being out of the 
question, immediate operation was practised. On opening the hernial 
sac it developed that its content was the stomach in its entirety, but 



492 STRANGULATED HERNIA. 

no gut was present. With great difficulty it was reduced. The pa- 
tient's condition did not permit of any further manipulation and shortly 
afterwards he succumbed. . Oliver expresses the opinion that the 
stomach had been forced dow-n into the sac by the strain, replacing the 
gut. 

Femoral Hernia. — Operation is even more urgent in the case of 
strangulated femoral hernia than in strangulated inguinal hernia. 
Gangrene is likely to develop earlier and taxis is all the more ineffectual 
by reason of the anatomical arrangement. Especially must one be 
on his guard in the case of small hernia for then the femoral ring is 
small and unyielding. It is essential to have the anatomy in mind to 
understand this and especially to operate without embarrassment. 

Surgical Anatomy. — Poupart's ligament stretches across the front of 
the pelvic region from the anterior superior spine of the ilium to the 
spine of the os pubis. The space between this band and the ramus 
of the pubis is occupied by several structures^from without inward, 
the iliacus and psoas muscles on their way to the lesser trochanter; the 
crural nerve, the femoral artery and vein, the femoral canal and Gim- 
bernat's ligament. 

Gimbernat's ligament is a firm triangular fascia with its base 
directed outward and abutting the femoral canal. 

The femoral sheath, a prolongation of the iliac fascia, encloses 
the femoral vessels. In the thigh it fits closely about the vessels. 

In the groin the sheath is more capacious so that there is a space 
left between its inner wall and the femoral vein. This space constitutes 
the femoral canal. The femoral canal is, therefore, conical in shape 
with its base above and its apex below where the sheath gets in contact 
with the femoral vein. The circumference of the base constitutes the 
femoral ring which is bounded internally by the base of Gimbernat's 
ligament; above, by Poupart's ligament; below, by the ramus of the 
pubes; externally by the femoral vein. The narrow orifice bounded 
by these structures is the usual site of strangulation of a hernia de- 
scending along this slender channel. 

It is Gimbernat's ligament whose sharp edge is most likely to 
shut off the circulation of a loop of intestine bulging past it and which 
is most likely to cut into or bruise the bowel in efforts at taxis (Fig. 374). 



OPERATION FOR STRANGULATED FEMORL HERNIA. 



493 



In other cases the hernia descending lower finds the direction 
of least resistance toward the surface and bulges out through the 
saphenous opening and the cribriform fascia. 

Operation. — If the operation is done early before complications, 




Fig. 374. — Relations of the neck of a femoral hernia under Poupart'; 
ligament. (MouUin.) 



such as gangrene, have arisen, the operation for strangulated femoral 
hernia is simple and without special danger. Begin by disinjecting 
the whole field; the inner surface of the thigh, the groin, the abdomen, 
the genitals. i > 

The incision may be vertical, following the axis of the tumor, or 



494 STRANGULATED HERNIA. 

oblique, below and parallel to Poupart's ligament; Lejars prefers the 
latter, claiming that it gives freer access to the femoral ring, facilitates 
the dissection of the sac and the procedures in the radical cure. 

The vertical incision is probably better for large and lobulated 
hernia which extend well below Poupart's ligament. But whatever 
incision is employed must be of ample length. 

The incision traverses the skin and then a fatty layer through 
which ramify a number of veins tributary to the long saphenous. 
Having divided this layer the sac is exposed, or at least the fatty envel- 
ope in which so often it is enclosed — a collection of fat which at times 
amounts to a veritable lipoma. The hernial sac lies immediately be- 
neath this fat — sometimes in thin subjects immediately beneath the 
skin — and presents itself in divers aspects. Usually it looks like a 
tense and reddish cyst; often it is lobulated. 

Second Step. Isolate the Sac. Proceed to separate it from the ad- 
jacent tissues by blunt dissection, peeling it out with the fingers, 
and disengaging it quite up to the neck. It is essential for the later 
steps of the operation that this be thoroughly done and is complete 
when Poupart's and Gimbernat's ligaments are well in -vdew. 

This dissection of the sac takes less time than one might expect 
and is greatly facilitated if one is able to find a Hne of cleavage be- 
tween the tissues. Sometimes bursas intervene between the sac 
and adjacent tissues and favor a rapid separation. 

Third Step. Open the sac; Examine the Contents. Once the 
hernial tumor is well exposed up to the constricting ring, cautiously 
incise the sac. Caution is required because often it is difficult to 
know when one has penetrated the sac and an adherent intestine may 
be wounded. In this form of hernia the true sac may be covered by 
a cyst, which may be filled by bloody serum and thus simulate the 
appearances of the hernial sac. A moment's examination, however, 
shows that it is a small closed cavity without communication with the 
abdomen. The layers are to be cautiously di\-ided one by one until 
the sac is opened into and the opening enlarged. 

Catch up the lips of the wound of the sac and examine its contents. 
Usually in this form of strangulated hernia one will see a small loop 
of intestine, darkened, tense and tightly constricted. Occasionally 



STRANGULATED UMBILICAL HERNIA. 495 

along with omentum there may be several loops of small intestine, or 
the cecum, or the sigmoid flexure. Irrigate the cavity and its contents 
with normal salt solution and prepare to relieve the constriction. 

Fourth Step. — Relieve the constriction. The first effort should be to 
relieve the strangulation by stretching the offending fibers, to this 
end introducing a finger, if possible, into the ring along the inner side 
of the hernia. 

Oftentimes the pressure thus exerted will, with a little effort, stretch 
and enlarge the opening sufi&ciently to relieve the constriction and 
to permit the necessary manipulation of the bowel. 

It may not be possible to introduce a finger and then one must 
resort to incision. To accomplish this a grooved director may be 
slipped up alongside the bowel and the fibers divided with scissors or 
bistoury; or if the fibers are in plain view, as they should be, they may 
be nicked with the point of the bistoury and when room is thus made 
the finger may be introduced as before. The use of the herniotomy 
knife, cutting blindly, should be reserved for exceptional cases, where 
the subject is fleshy and the obstruction beyond reach and very tight. 
' But whatever method may be practised one must keep to the in- 
side; cutting inward or upward to avoid injury to the bowel or the 
femoral vein. 

When the obstruction is removed pull the bowel down and examine 
it. If it is suspicious or gangrenous, treat it after the manner indi- 
cated under strangulated inguinal hernia. 

If it is sound, reduce it; liberate the sac around the femoral ring, 
ligate and resect it; and close in some manner the femoral canal. 
(See operation for radical cure.) The after-treatment is the same as 
for inguinal hernia. 

It remains to be said that in exceptional cases it may be necessary, 
in order to see what to do, to divide Poupart's ligament, or in the male 
where the cord is to be avoided to make another incision along the 
inguinal canal, exposing the neck of the hernia; or, following the 
method of Tuffier, to open directly into the peritoneal cavity through 
the inguinal canal. 

Strangulated Umbilical Hernia. — A strangulated umbilical hernia 
is peculiar in two or three respects. It is likely to be deceptive in that 



496 STRANGULATED HERNIA. 

the characteristic symptoms of intestinal obstruction may be wanting. 
The site of strangulation is more likely to be in the sac than at the um- 
bilical ring. But because the absolute signs of obstruction are absent 
and because the opening at the umbilicus seems patent, one has no 
excuse to delay when an old and long irreducible rupture becomes 
suddenly painful, with vomiting and partial constipation. 

Too often, as Lejars says, we call these attacks with comparatively 
mild onset, pseudo-strangulation and so the case drifts along while 
septic absorption goes on insidiously but surely. From day to day 
the circulation grows weaker, the abdomen more tympanitic, the 
vomiting more pronounced, until the vital forces are practically over- 
come, at which time, too late, it is decided to operate. The expectant 
treatment and repeated taxis in these cases are merely methods of 
"losing time." 

Following such practice one can confidently expect a large per- 
centage of fatalities, though one should not hesitate to operate even 
in the face of such odds. Operating early one may give assurance of 
excellent results. To quote Lejars again, it is not the operation which 
is to be feared; it is the delay. 

Operation. — Careful disinfection of the whole abdominal wall; a 
prudent and cautious anesthesia. The incision may follow the median 
line extending well beyond the tumor above and below; or in the case 
of a large tumor, may consist of two semilunar incisions on either side 
of the middle line which enables one to get rid of redundant tissue. 

In either case the incision must not go deep from the first for often 
the skin is quite thin, often adherent to the sac and it is easy to go 
directly into the sac. By reason of this adhesion at the center of the 
tumor, begin the dissection at the poles of the incision and work toward 
the center. 

As soon as the skin is detached proceed to isolate the tumor, if 
possible, up to its point of emergence. It may not be practicable 
if the tumor is large and lobulated to take the time, and in such a case 
the sac may be opened into at once. 

Second Step. — Open the Sac. Detach the omentum. Nearly always 
on first opening the sac only omentum can be seen. It completely 
envelopes the bowel. The fingers are gently insinuated between the 



OPERATION FOR STRANGULATED UMBILICAL HERNIA. 497 

omentum and the sac, and the adhesions progressively broken down. 
Wherever a lobule of omentum is found encysted in a diverticulum 
of the sac, it must be dissected out in the same manner. Finally the 
entire omentum will be freed, may be lifted up and the gut exposed 
(Fig. 364). 

Irrigate both the bowel and omentum with normal salt solution, 
wipe with sterile gauze and examine the bowel carefully to see that there 
is no danger of perforation and of soiling of the peritoneum in the 
process of reduction. 

Third Step.^Relieve the Strangulation. Oftentimes the umbilical 
ring may need only to be stretched a little to permit the free manip- 
ulation of the bowxl; again, it may be necessary to divide the con- 
stricting fibers. This may be most readily accomplished by pulling 
down the omentum, slipping a finger between it and the upper part of 
the ring to the left of the middle line. If this nick does not give suffi- 
cient release, repeat on the opposite side. 

When the necessary room is obtained, ligate the omentum, resect 
it, cleanse the stump and reduce it that there may be nothing to inter- 
fere with the treatment of the bowel. 

With respect to the bowel, the same principle of treatment holds 
good as in inguinal hernia. Repair any slight defects or abrasions. 
If its viability is doubtful, keep it under observation for a few hours. 
If gangrenous, either anchor it in the wound and make an artificial 
anus or do an enterectomy. 

It may be that in very large umbilical hernia it is better to modify 
the procedure following the plan of Mayo, and others, in order to 
gain time. 

A transverse elliptical incision is made around the tumor at such 
distance from the center that the redundant tissue shall be removed. 
Cut dow^n to the sac. Next cautiously open the sac following the skin 
incision. Apply several forceps to the edges of the sac so that it is 
constantly under control. Detach the omentum, freeing it completely 
up to the neck of the sac. Ligate and resect it, and working along its 
under surface free it from the bowel. Once detached the paquet of 
omentum carries with it a segment of the skin and of the sac. 

The bowel is next treated and reduced. This may not be as easily 
32 



498 



STRANGULATED HERNIA. 



done as said for there are several circumstances under which the 
bowel may push out and threaten eventration. But no effort should be 
made to push back the rebellious loops en masse. 
Proceed at once to enlarge the opening, lift up the edges of the 




Fig. 375. — Umbilical hernia: dissection of sac. (Mayo.) 



peritoneum by the attached forceps and cover the bowel with a wide 
compress, tucking its edges under the belly walls on all sides, as de- 
scribed elsewhere. As little by little the bowel is returned the edges of 
the compress are slipped farther under. When reduction is complete 
the compress is left in situ until the sutures are placed. 

Fourth Step. — The mode of repairing the abdominal wall varies 



REPAIR OF THE ABDOMINAL WALL. 



499 



with the circumstances and the operator, and depends upon how much 
time one may dare take. When the condition of the patient im- 
poses great haste it must suffice to pass interrupted sutures through 
the whole thickness of the belly wall and draw the edges of the wound 




Fig. 376. — Umbilical hernia; repair of abdominal wall. (Mayo.) 



together so that the peritoneal edges point out and the two serous 
surfaces are thus brought into contact. Before the last suture is tied 
the compress is removed; and finally a continuous suture will com- 
plete the reunion. 



500 STRAXGULATED HERXL4. 

If more time is available, after the sac is trimmed its edges are 
sutured as after a laparotomy. The sheaths of the recti muscles 
are opened up and the inner border of each muscle exposed. The two 
sides are then brought in contact and three tiers of sutures applied; 
one uniting the deep layer to its fellow of the opposite side; the second 
uniting the two muscles; the third uniting the two superficial layers of 
the sheath. 

Finally the excess of subcutaneous fat is trimmed away and the 
skin sutured. The usual dressing is used, held in place by a wide 
binder, and the after-treatment, already indicated, is instituted. 

Figs. 375 and 376 show the manner in which Mayo perfects the 
radical cure. 

Obturator Hernia. — A strangulated obturator hernia is rare, yet it is 
to be thought of and ruled out before opening the abdomen for in- 
testinal obstruction. Several points help to locate the trouble even 
when no marked tumor is present. The presence of pain over the 
region of the obturator foramen directs the attention to that point and 
pressure made there, projects a pain down the inner side of the thigh 
to the knee, along the course of the obturator nerve. In the female, 
vaginal examination will reveal the tumor. 

In this form of strangulated hernia, taxis is useless and likely to be 
very harmful, and therefore must never be employed. A herniotomy 
must be done without delay, though in these cases it is a procedure 
by no means simple. Several anatomical points must be borne in 
mind. The hernia usually comes out through the upper part of the 
obturator membrane and is covered over by the pectineus muscle. 
It may work into the pectineus or it may lie on a lower level, working 
into the obturator externus. The pectineus is usually the chief guide 
to the hernia. 

The obturator vessels and nerve are usually found behind and 
to the outer side of the neck of the hernia, though one cannot count on 
that. The femoral vessels lie to the outer side. It is the obturator 
membrane which constitutes the constricting ring. 

The operation, chiefly as described by Treves, is as follows: The 
pelvis is elevated, the thigh flexed and adducted, the femoral artery 
located, and about a finger's breadth internal an incision is made from 



STRANGULATED OBTURATOR HERNIA. 



501 



the spine of the pubes downward for three or four inches. Incise the 
skin, the subcutaneous fat and the fascia lata and expose the adductor 
longus. Catch up the deep external pudic artery. Retract the 
adductor brevis and beneath this is the pectineus whose fibers are 
separated by blunt dissection, or, if necessary, divided in order to 
expose the sac (Fig 377). 




Fig. 377. 



-Obturator hernial. A. Hernial sac -obturator artery. 
C. Adductor longus. (Lejars.) 



B. Pectineus. 



When the sac is once in view, free it completely up to the neck. 
The obturator membrane is now to be nicked, observing first the 
course of the arteries. It is better, however, to open the sac at once, 
cleanse the contents and endeavor to insinuate the finger alongside 
the bowel and stretch the strangulating fibers; failing in this, to divide 
them, keeping in mind the possibility of a hemorrhage. If in spite of 



502 STBAXGULATED HERXIA. 

precaution tliis occurs, tampon firmly against the obturator mem- 
brane and when the tampons are removed one by one, the bleeding 
points may be recognised and clamped. Finally the intestine, if 
sound, is reduced, the sac dissected and Kgated high up and the ex- 
ternal wound sutured. 

Lejars remarks that one may find in the sac of a strangulated 
obturator hernia not only bowel and omentum, but also the tubes and 
ovaries, the bladder and the appendix; and that it is well to be fore- 
warned of these possibilities, which may greatly complicate an opera- 
tion at best never simple. 

Of strangulation of other forms of hernia — sciatic, lumbar, perineal, 
vaginal — it need only be said that they are too rare to be with profit 
considered here. 



CHAPTER XL 
RADICAL CURE OF INGUINAL HERNIA. 



The radical cure of hernia may be attempted at the operation for 
strangulated hernia under the conditions defined. But aside from 
those emergency cases there are others in which the family doctor 
will feel it his duty to recommend and to do the operation. His 
results will be excellent if he wisely chooses 
cases not beyond his skill. As Veau says he 
should select only such as are small, reducible, 
congenital. The large hernias are difficult to 
handle and recurrence will be almost certain. 
The irreducible hernias may have acquired ad- 
hesions that can scarcely be broken up without 
severe injury to the gut. With respect to age, 
the ideal case is a young man fifteen to twenty- 
five years old, who has well-developed ab- 
dominal walls, a well-defined external abdom- 
inal ring and a hernia easily controlled by a 
truss. 

Under these favorable conditions, the hernia 
rarely recurs ; but almost certainly it will recur 
if suppuration follows the operation, and there- 
fore absolute asepsis is the. sine qua non of 
success. 

Surgical Anatomy. — The hernia, then, 
which the general practitioner should under- 
take to operate on is an external or oblique, which escapes from the 
abdominal cavity through the internal ring to the outside of the deep 
epigastric artery and follows the inguinal canal down to the external 
ring (Fig. 378). 

Beneath the skin will be found only a few insignificant vessels. 

•503 




Fig. 378. 



Transverse 
vertical section of the in- 
guinal caqal showing rela- 
tion of the hernial sac. GO, 
external oblique; PO, in- 
ternal oblique; T, transver- 
s a 1 i s ; Ft, transversalis 
fascia; P, peritoneum; TC , 
conjoined tendon; Creiu., 
cremaster; cd, vas deferens 
in contact with the hernial 
sac represented in black. 
(Veau.) 



504 



RADICAL CURE OF INGUINAL HERNIA. 



The aponeurosis of the external oblique is -easily distinguished, 
strong and resistant, and its fibers bounding the external ring are 
thickened to form the "pillars" of the ring. Behind it lies the cord, 
which includes the vas deferens and its accompanying vessels and 
nerves, all surrounded by a common sheath derived from the trans- 
versalis fascia, and in this case, it contains also the hernial sac. To 
reach the sac, the sheath must be divided and the elements of the cord 
separated from the sac. 




Fig. 379. — The primary incision for hernia, (Veau.) 



In the case of congenital inguinal hernia, the sac is very thin and 
in spite of precautions, it is sometimes torn or one even fails to find it. 
The chief difficulty of the operation centers around the recognition 
and dissection of the sac. The posterior wall of the inguinal canal 
is formed by the conjoined tendon, the transversalis fascia and the 
peritoneum. 

The purpose of the operation is to reconstruct the posterior wall 
and restore the obliquity of the canal and the "Bassini" operation 
is the type the inexperienced operator can best imitate. 

Operation. — Prepare the field most scrupulously, abdomen, thigh 



INCISION FOR INGUINAL HERNIA. 



505 



and scrotum. Employ general anesthesia as a rule, although local 
and spinal anesthesia are a\ailable. 

Begin by locating the external ring, which is to be the first point 
of attack. 

The incision will extend from this orifice to a point just over the 
internal ring, which lies one-half inch above the middle of Poupart's 
ligament. The incision, then, beginning above (on the right) (Fig. 
379) extends downward and forward to the spine of the pubes, where 




Fig. 380. — -The external oblique exposed and the external ring developed. (Vea,u. 



it bends a little to become more vertical and ends in the base of the 
scrotum. However large the hernia may be, one need not extend 
the incision further, so lax and distensible are the scrotal tissues. 

Having divided the skin and subcutaneous tissues, catch up and 
ligate the small vessels. Next divide the fatty tissues layer by layer 
down to the aponeurosis of the external oblique, which lies deeper 
than one may expect. 

Now, with the grooved director, completely expose the pillars of the 
ring. Do not neglect this as it is a most important step in the oper- 



5o6 



RADICAL CURE OF INGUINAL HERNIA. 



ation. The inner pillar is easily found, but the outer pillar is covered 
by the cord and a little patience is required to get it well exposed. 
Catch up each pillar with forceps; these are not to be loosened until, 
at the end of the operation, they have served as a guide in the repair 
of the external ring (Fig. 380). 

Now comes the next step in the operation. Carefully divide the 
aponeurosis in the line of the pillars and to the full extent of the skin 
wound. Unless one cuts deeply, there is nothing to fear. You have 
now laid open the inguinal canal and have left to do the most diflScult 
part of the operation. 




Fig. 381. — The external oblique divided, exposing the cord and hernial sac. (Veau.) 



To Find and to Dissect out the Sac. — The cord is covered by the 
cremaster which also covers the hernial sac. You may begin the 
search for the hernial sac without disturbing the position of the cord, 
but it is better to raise it up out of its bed. To do this follow along 
the external pillar and Poupart's ligament and you will find it easily 
disengaged by blunt dissection (Fig. 381). Slip the left index finger 
under and support the cord. The sac is enclosed in the fibrous sheath 
of the cord. 

Very gently incise this sheath using a sharp bistoury (Fig. '382) 
and the structures of the cord appear. Rolling them between the 
finger and thumb, you can recognize the vas deferens by its form and 
consistency. You can see the distended veins. You will see a 



EXPOSING THE HERNIAL SAC. 



507 




Fig. 382.— Dividing the fibrous coverings of the sac. (Veau.) 




Fig. 383. — Incising the hernial sac. 



(Veau.) 



508 



RADICAL CURE OF INGUINAL HERNIA. 



whitish transparent membrane. Catch up a fold of it with the 
forceps and divide its base, and if it is the sac, you will open into a 
serous cavity (Fig. 383). Enlarge the orifice sufficiently to introduce 
a finger and with that as a guide, dissect the sac from its associated 
structures (Fig. 384). It is often a difficult task, for the veins and 
vas deferens are glued to the sac, especially in the congenital hernia. 




Fig. 



384. — The index finger introduced into the sac which is being separated 
from the other structures of the cord. (Guibe.) 



Sometimes pressing and stripping the tissues back with a gauze 
compress facilitates the manoeuvre. 

It is important that the sac be isolated quite to the internal ring 
(Fig. 385); otherwise when the ligature is applied there will be formed 
a peritoneal diverticulum, the starting point later of another hernia. 
Do not carry the dissection further than the internal ring for fear of 
wounding the bladder. 

Assure yourself now that the sac is empty by passing a finger up 



DISSECTING AND LIGATING THE SAC. 



509 




Fig. 385. — The sac separated from the cord; the cord in the bottom of the wound, 
on either side the lips of the external oblique. (Veau.) 




Fig. 386. — Ligation of the neck of the sac. (Veau.) 



5IO 



RADICAL CURE OF INGUINAL HERNIA. 



into the abdominal cavity. Now transfix the neck of the sac with a 
needle carrying a catgut ligature (Fig. 386) and tie in the manner 
indicated in figure (Fig. 387). If the ligature merely encircles the 
neck, it is too likely to slip off. Do not cut off the ends of the ligature 
until through dealing with the sack. Amputate the sac within one- 
half inch of the ligature and if everything is all right, cut the threads 
and the stump disappears in the cavity. 

Suture of the Abdominal Walls. — This is the next step. Draw the 
cord down out of the w^ay for the moment and expose the shelving 




Fig. 387- — Illustrating method of 
iigating the sac. (Veau. 



Fig. 388. — The cord drawn to one side while the 
posterior wall of the canal is restored by suture 
of the conjoined tendon to the shelving edge of 
Poupart's ligament. (Veau.) 



inner edge of Poupart's ligament, which is to be sutured to the free 
border of the conjoined tendon. In other words the internal oblique 
and transversalis are to be sutured jointly to Poupart's ligament. 

Through this shelving edge near the pubis pass a chromic catgut 
suture on a curved needle and carry it. through the corresponding 
part of the conjoined tendon (Fig. 388), and apply three or four such 
sutures (Fig. 389). In this manner reconstruct the posterior wall of 
the inguinal canal. Place the cord back in position upon this line of 
sutures. 

Now draw the edges of the divided aponeurosis into position by 
means of the forceps attached to the pillars at the beginning of the 
operation. Begin the repair by a chromic catgut suture at the upper 
end of the wound (Fig. 390) and pass six or eight in this manner. 



SUTURE AND DRESSING OF THE WOUND. 51I 

The last will rejoin the pillars and restore the external ring, and when 
these are all tied the anterior wall of the canal is thus reconstructed. 
There is little danger of making the external ring too small for the 
cord (Fig. 391). 

Complete the hemostasis. A scrotal hematoma may develop 
unless one is very particular about the oozing. 

Complete the operation by suture of the skin wound with silkworm- 
gut, leaving in it a small drainage tube if you fear infection or oozing, 
otherwise this is not necessary; still it does no harm. 

Cover the wound with a strip of moist gauze, fix it with collodion, 
and then apply the ordinary gauze and cotton dressing. A double 




Fig. 389. — Posterior wall-repair complete. (Veau.) 

spica bandage will greatly diminish the chance of infection. If 
drainage was employed, remove the tube in two or three days under 
strictest asepsis. Otherwise do not disturb the dressing but watch 
the temperature. If the temperature runs up to 101° on the third 
day, open up the wound by removing one or two sutures, and if there 
is any pus, drain. 

Delay in this is likely to result in extensive suppuration and a 
recurrence of the hernia is thus assured. If everything goes well, 
remove the stitches on the eighth day but keep the patient in bed for 
three weeks. A truss is not necessary. 

Rilus Eastman, of Indianapolis, recommends a modification of the 
final suturing especially applicable in the case of children. His 
method aims at the closure of all the layers by a single tier of easily 
removable non-buried sutures. The method described (Annals of 



512 



RADICAL CURE OF INGUINAL HERNIA. 



Surgery, Jan., 1906) consists in the reduction of the sac by the ordinary 
procedure. A Pagenstecher celloidin linen suture bearing a needle 
on each end is then first passed through Poupart's ligament from 
without inward one inch from its free margin. It is next passed 
through the outer border of the obliquus externus and transversalis 
muscles and brought back through Poupart's ligament about -J inch 
nearer the margin than at its first point of passage. The needle now 
external to and above Poupart's ligament is made to overlap the free 





Fig. 390. — Reconstructing the anterior wall 
by repair of the external oblique. Forceps 
still attached indicate the position of the 
ring. (Veau.) 



Fig. 391. — External oblique 
repaired. (Veau.) 



margin of the ligament and the aponeurosis of the external oblique 
by carrying the thread through in the form of a simple running mat- 
tress suture. 

The needle is next passed through the superficial fascia, panniculus 
adiposus, and skin, emerging about J inch from the skin wound 
margin upon the side opposite Poupart's ligament. When traction 
is made upon the two ends of the suture no kinks or curls remain and 
the suture is tied up as a simple loop. Five or six such sutures are 
required to coapt the wound from the internal ring to the pubes. 
When union is complete they are easily clipped and removed. 



CHAPTER XII. 
RADICAL CURE OF FEMORAL HERNIA. 

Aside from the cases of strangulated hernia, the general practi- 
tioner should not undertake the operation for the radical cure of 
femoral hernia without due consideration and without warning the 
patient that relapse is possible and even frequent. The operation 
is not more difficult than that for inguinal hernia, but a cure is much 
less certain. As with inguinal hernia, he should select only such 
cases as are small and reducible. 

Surgical Anatomy. — The sac of a femoral hernia is generally thick 
and imbedded in adipose tissue originating in the extra-peritoneal 
layer. (See strangulated femoral hernia.) 

The relations at the neck are of the greatest importance. To the 
outside is the femoral vein in direct contact, easily perforated by a 
careless needle and producing a hemorrhage that can be arrested only 
by ligature of the vein. To the inside is Gimbernat's ligament, sharp- 
edged and tense, the chief structure to be dealt with in strangulation. 
Above is Poupart's ligament, separating the femoral from the inguinal 
canal, and below is the ramus of the pubes, thinly covered by the 
pectineus and its fascia. These boundaries are unaccommodating 
structures in the matter of repair, and for this reason relapse is 
frequent. 

Operation. — The anesthesia and preparation are the same as for 
inguinal hernia. 

The incision, parallel with, and a finger's breadth below Poupart's 
ligament, begins (on the left side) at the spine of the pubis and is 
usually about four inches in length (Fig. 392). 

Incise in the same manner the fatty tissues, layer by layer, until the 
easily distinguishable coverings of the hernia are reached. The line 
of cleavage between them and the fatty tissues is followed and the 
neck, lying high and deep, is exposed. Where the coverings seem 

33 513 



514 



RADICAL CURE OF FEMORAL HERNIA. 



thinnest, catch up a fold with the dissecting forceps and incise the 
base. It may be that the incision will only open into another fatty 
layer. Divide the next layer in the same manner, and so proceed until 
you have opened the sac; secure its edges with forceps and pass an 
index finger into the cavity. If omentum is found it must be resected 
(Fig. 393). Be sure there is no adherent bowxl. 

Now dissect the sac, proceeding slowly and methodically until the 
femoral ring is reached. Introduce a finger to be sure the bowel is 




Fig. 392. — Incision for femoral hernia. (Veau.) 



protected, and transfix and ligate the neck of the sac as in inguinal 
hernia. Again recall the relations of the femoral ring (Fig. 394). 

Obliteration of the Femoral Ring. — Retract the upper angle of the 
wound so that you can see, and with the edge of the bistoury held 
horizontally, divide Gimbernat's ligament freely (Fig. 395). Poupart's 
ligament can now be approximated to the pectineus. Protect the 
femoral vein with a retractor and pass the first suture adjoining it, 
using a strong curved needle and No. 2 or No. 3 catgut. 

The needle enters the pectineal fascia, grazes the bone, comes 
out a little higher, and then passes up to the posterior surface of the 



CLOSURE OF THE FEMORAL RING. 



515 



ligament and forward through it (Fig. 396). Place four sutures in 
this manner before tying (Fig. 397). Tie them successively from 
without inw^ard. It is this line of suture alone that will be efficient, 
but suture the fascia if you wish, and finally the skin. 

The subsequent treatment is the same as in inguinal hernia. 

Such is the method which Veau recommends, and which has the 
great merit that it is anatomical. But there are many differences 
of opinion as to the best method of closing the femoral ring, and as 
to the advisability of even closing it at all. 







Fig. 393. — Resection of the omentum. (Guibe.) 



Oschner enunciates the principle, applying it to the radical cure 
of femoral hernia, that circular openings in any part of the body, 
will certainly close unless kept open by a mucous or serous lining. 
Wherever, therefore, the femoral ring is well defined, he is content 
with high ligation of the sac and dissection of all the fat and simple 
closure of the wound. With a technique thus reduced to the simplest 
terms, he obtains excellent results. Unfortunately, the femoral ring 
cannot always be defined as a circular opening, and especially after 
the operation for strangulated hernia. 

Coley in the main agrees with Oschner, but lays some^^ hat more 



5i6 



RADICAL CURE OF FEMORAL HERNIA. 



stress on the closure of the femoral canal. His method, described 
briefly in Progressive Medicine (June, 1907) is as follows: — 

An oblique incision is made one-quarter to one-half inch below 
Poupart's ligament and parallel with it, almost identical with incision 




Pig. 394. — The neck of the sac 
i gated and cut off. Above, Poupart's 
ligament; below, the ramus of the 
pubes; internally, Gimbemat's liga- 
ment. (Veau.) 




Fig. 395. — Femoral hernia; incision of 
Gimbemat's ligament. (Veau.) 




Fig. 396. — Suturing Poupart's liga- 
ment to the pectineal fascia. (Veau.) 



Fig. 397. — Suture of Poupart's ligament and 
pectineal fascia completed. (Veau.) 



made for inguinal hernia, only slightly lower and a little shorter. 
The sac with the mass of extra-peritoneal fat that almost always sur- 
rounds it, is then freed well up into the femoral opening. The masses 
of fat are carefully removed; the sac itself, by gentle traction, is brought 



CLOSURE OF THE FEMORAL RING. 



517 



down well beyond its neck to a point where it widens into the general 
peritoneal cavity. It is always opened before ligature, to make sure 
it is empty. If omentum is present, this is tied off and removed, the 




J. xvj. 398. — Closure of femoral ring. 
Sutures passed through Poupart's liga- 
ment and the pectineal fascia. (Binnie.) 




Fig. 399. — Suture of femoral ring com- 
pleted, by passing sutures through the 
plica falciformis and pectineal fascia. 
(Binnie.) 



sac is transfixed, resected, and reduced. With a curved Hagedorn 
needle threaded with kangaroo tendon of medium size, the suture 
is placed, ' passing the needle first through the inner part of Poupart's 
ligament, then downward through the fascia lata overlying the femoral 



Fig. 




Roux's operation for closure of the femoral ring. (Binnie.) 



vein, and finally upward, emerging through the roof of the canal 
one-quarter inch distant from the point of entrance. On tying this 
suture the floor of the canal is brought into apposition with the roof 



5l8 RADICAL CURE OF FEITORAL HERNIA. 

and the femoral opening is completely obliterated. The skin and 
superficial fascia are closed with uninterrupted catgut suture. The 
first change in dressing is made in a week, and the patient is allowed 
to go home at the end of two and a half weeks. 

Another method is represented in Fgures 398 and 399. In Roux's 
operation, Poupart's ligament is brought down to the pubes by a 
metal or ivory steeple (Fig. 400). 



CHAPTER XIII. 
ENTERECTOMY. INTESTINAL ANASTOMOSIS. 

Resection of a segment of the small intestine may be a necessary- 
part of several emergency operations. It may be required following 
gunshot or other lacerating wounds of the intestine; it may be necessary 
in certain wounds of the mesentery; and in the gangrene of strangu- 
lated hernia. 

Large wounds of the gut, those which carry away more than one- 
half the circumference require resection, for any form of repair is likely 
to result in stricture. In the case of multiple perforations, it is 
safer to resect than to attempt separate repair of the orifices. A 
small wound of the omentum near the intestinal border may require an 
extensive resection, for an inch of mesentery at that level may contain 
the blood supply of two feet of intestine. 

Resection of the bowel implies anastomosis, and this may assume 
one of three forms: it may be end-to-end — termino-terminal; termino- 
lateral; or latero-lateral. 

The end-to-end anastomosis is preferable following resection. 
The method employed may be either by suturing — circular enter- 
orrhaphy — or by the Murphy button, or some of the other mechanical 
devices, such as Robson's bone bobbin, or Frank's decalcified bone 
coupler. With the great majority of surgeons, suturing is the method 
of choice, although the casual operator may not yet be ready to dis- 
card the mechanical device. 

Moynihan in his great work on abdominal operations sums the 
matter up in this wise: "The use of mechanical appliances is no 
longer necessary; these have played their part — a most important 
part, I gratefully admit — in the development of surgical work and it 
is now time that their surgical use should be abandoned. They have 
been useful, nay, indispensable steps in the march of progress. To 
Murphy above all other surgeons — for his instrument is one of the 

519 



520 ENTERECTOMY. INTESTINAL ANASTOMOSIS. 

most ingenious mechanical contrivances ever invented — we should 
gratefully acknowledge the debt we owe. The weightiest argument 
against all mechanical aids to anastomosis is this— they are unneces- 
sary. By their aid we do not accomplish anything which cannot 
be accomplished with equal rapidity and greater safety by simple 
suture. We have nothing to gain from their use and we risk much 
by leaving something behind w^hich may be and has been the direct 
cause of danger and of death. The day of mechanical aids is over. 
The buttons and the bobbins, the elastic ligatures and the forceps of 
many forms have no more than a historical interest." 

Technique of Resection. — The first essential of this procedure is 
that all the impaired gut be removed. Otherwise subsequent slough 
and perforation are almost a certainty. There is a limit of course to 
the length of the segment which may be safely removed, but in the ordi- 
nary operation one need not fear to remove too much. Cases are on 
record in which as much as lo feet of the small intestine have been re- 
moved with recovery. As Moynihan said, it is not so much a question 
of how much is removed as how much is left to carry on the intestinal 
functions. A second requisite in resection is that the blood supply of 
the bowel be left unimpaired. Lack of precaution in this respect may 
nullify an otherwise careful operation. 

The integrity of a given part of bowel is absolutely dependent 
upon the condition of the vessels which arise from the last arterial arch 
to supply it. It must be remembered that the vasa intestini tenuis 
break up into a number of freely anastomosing arches, but the terminal 
branches anastomose but little. It is this character of the circulation 
which determines the mode of section of the mesentery. 

The second principle constantly to be borne in mind is that the perit- 
oneum is to be completely protected from contamination by the bowel 
contents. It is true of all the hollow viscera that their contents are 
more or less septic, always sufficiently so to produce peritonitis. The 
bowel then must always be temporarily constricted beyond the limits of 
the section. This is ordinarily done by means of intestinal clamps, or 
by elastic ligature, or by gauze strips passed through a button-hole in 
the mesentery. 

Not only must the intestinal contents be restrained but also the 



RESECTION OF THE GUT. 52 1 

field of operation must be shut off from the peritoneal cavity and from 
contact ^Yith the rest of the viscera by means of sterile compresses. 
The larger and more deeply placed of these are not to be removed until 
the end of the operation; the smaller and more superficial should be 
changed from time to time as soiled. 

To resect a portion of the intestine, then, begin by getting the 




Fig. 401. — Resection of the bowel; showing Hnes of incision of bowel and omentum. 

injured coil well into view and pack around it with sterile compresses. 
It may be advisable as a further security now to put the patient in the 
Trendelenburg position. Strip the portion of bowel to be removed, so 
as to empty it, and apply a clamp well beyond each end of the con- 
demned segment. The clamps are not placed directly across the 
bowel, but obliquely, so that more of the convex than of the mesenteric 
border is included. A portion of the mesentery is included in the bite 
of the forceps. 



522 



ENTERECTOMY. INTESTINAL ANASTOMOSIS. 



The lines of the section are prolonged into the mesentery so that 
they meet just short of the nearest arterial arch. It is better to make 
the base of the mesenteric wedge even narrower than the mesen- 
teric margin of the intestinal segment. There is then scarcely any 
danger that the circulation will be impaired (Figs. 401, 402). 

Technique of Anastomosis. — (a) By Suture. Employ two lines of 




Fig. 402. — Resection of bowel; showing segment of bowel and omentum removed. 



suture. One perforates the bowel wall, brings the cut edges into ac- 
curate contact and is hemostatic; it may be called the "perforating" 
suture. The other passes only through the serous and muscular coats 
— or even better the sub-mucous — and after the manner of the Lembert 
suture brings the serous surfaces into contact, buries the perforating 
sutures and effectually prevents any of the bowel content from reach- 
ing the peritoneal cavity. Most surgeons employ a straight needle 
and silk. Moynihan likes the curved needle and celluloid thread. 



END-TO-END ANASTOMOSES. 



523 



To introduce the suture begin by placing the clamps side by side, 
bringing the posterior surfaces of the bowel into contact. Con- 
nect these two surfaces by a continuous sero-serous suture, extending 
from the mesenteric border to the convex border (Fig. 403). Leave 
the thread long where tied at the point of beginning and catch it 
with forceps. On reaching point "B" leave the needle still threaded 
but wrap it in gauze and lay it aside for the moment. 

Now begin the perforating suture at the mesenteric margin. The 
two leaves of the mesentery separate here to encircle the bowels, 




Fig. 403. — -End-to-end anastomosis; the first part of the sero-serous or Lembert 
suture applied. Beginning'the inclusive suture. (Binnie.) 



leaving a part of the surface bare. The stitch must be passed so as to 
bring the mesentery in contact with this bare area. 

Proceed in this manner: Pass the needle through the bowel wall 
(beginning with the right side) about \ inch from the cut edge, enter- 
ing the mucus, emerging from the serous coat just where the mesentery 
reaches the bowel. Carry the needle over and across to the left side, 
pass it through into the lumen, reversing the first puncture. Pass it 
next from within out, perforating the wall near the mesenteric juncture, 
and finally perforate the right bowel wall again passing from without in- 
ward. The knot is tied within the lumen of the gut at the original 
point of entrance. The edges of the mesentery being thus brought 



524 



ENTERECTOMY. INTESTINAL ANASTOMOSIS. 



together, the suture is carried continuously around the whole circum- 
ference of the gut (Fig. 404). The punctures are -^-q to -^-^ inch apart 
and the work is facilitated by keeping the thread taut, which at once 
tightens it sufi&ciently and brings into view the site of the next punc- 
ture. The end of the suture is knotted, the thread left long at the 
beginning and thus the perforating suture is completed. Remove the 
clamps. 

'A 




Fig. 404. — End-to-end 'anastomosis; the first part of the Lembert suture buried by the 
inclusive suture which will be completed before resuming the Lembert A B. (Binnie.) 

It remains to complete the sero-serous suture which was temporarily 
abandoned. It is carried from the convex border on around to 
the mesenteric border and when that point is reached the perforating 
suture is completely buried. Knot with the thread left long in the be- 
ginning and held with forceps, and thus the sero-serous suture is com- 
pleted (Fig. 405). Finally suture the rent in the mesentery. This 
must never be neglected else it may be the site of a strangulated 
hernia. The line of suture is to be carefully wiped, the compresses re- 
moved and the loop returned to the abdominal cavity. 



ANASTOMOSES BY MURPHY BUTTON. 



525 



(b) By the Murphy button (Fig. 406). The bowel is resected as de- 
scribed above. Begin by passing a purse string suture around the 
bowel near its cut edge, involving all the layers. The chief concern is 
to get control of the mesentery where its layers separate. To do this 

'A 




Fig. 405. — End-to-end anasto- 
mosis completed. A and B to be 
knotted. (Binnie.) 




A P" B 

Fig. 406. — Murphy button. 




Fig. 407. — Purse 
string suture (&) run- 
ning over edge of bowel 
and closing space 
between mesentery (c) 
at (a). (Stewart.) 



Fig. 408. — Anastomosis with Murphy button completed. 
(Binnie after DaCosta.) 



pass the needle through one layer, on into the lumen of the bowel; 
out again through the bowel wall and through the other layer of mesen- 
tery (Fig. 407). 

When the suture is puckered the intermesenteric space is obliterated. 



526 



ENTERECTOMY. INTESTINAL ANASTOMOSIS. 



Now grasp one-half of the button with forceps and introduce it into 
the end of the gut so that when the purse string suture is tightened 
it will fall into the groove in the button. 

Adjust the other half of the button in the same manner. The 
male half is pressed firmly into the female half, noting that all the 








Fig. 409. — Lateral anastomosis facili- 
tated byuse of clamps. Continuous suture 
for both layers. (Binnie.) 



Fig. 410. — Lateral anastomosis; first 
row of Lambert sutures applied (Binnie.) 



edges are turned in. Strengthen the union by a few Lembert sutures. 
Repair the rent in the mesentery and the anastomosis is complete 
(Fig. 408). It may be expected that the button will pass about the 
tenth day. 

Lateral Anastomosis. — Proceed as before, bringing out of the ab- 
dominal cavity the loops to be anastomosed and pack with sterile 



TECHNIQUE OF LATERAL ANASTOMOSIS. 



527 



compresses. Each loop is clamped and the two clamps laid side by 
side as to bring about 5 inches of the bowel walls in contact (Fig. 409). 




Fig. 411. — La t er al anastomosis; 
first part of the through and through 
suture applied. (Binnie.) 



Fig. 412.- — Lateral anastomosis. Applying last of 
the Lembert sutures. Interrupted in this case, use 
the continuous instead. (Binnie.) 



The first line of suture is to be applied nearer the convex than 
the mesenteric border and should be about 3 inches in IcngtJi. Unite 



528 ENTERECTOMY. INTESTINAL ANASTOMOSIS. 

the opposed surfaces, then, by a sero-serous suture. The line of 
suture runs toward the operator and when the line has reached, say 3 
inches, the needle is left still threaded and temporarily laid aside. 

The next step consists in making the openings which are to afford 
the means of communication between the two loops. A straight 
incision about J inch from and parallel with this line of suture lays 
open the bowel down to the mucosa. Section of these superficial coats 
leave exposed an ellipse of mucous membrane and this ellipse should 
be trimmed out with the scissors. The other loop is opened in the 
same way. 

The adjoining edges are now to be coapted by continuous per- 




FiG. 413. — Cross section of lateral anastomosis. (B 



linnie.) 



f orating suture (Fig. 410). As this suture progresses the opposite angle 
of the wound is reached, but without interruption it continues to draw 
together the more widely separated borders. (Fig. 411). 

When it has reached the point of beginning, the terminal thread 
is knotted with the first which was left long, and so the perforating 
suture is finished. Remove the clamps, wipe the bowel, and now 
return to the sero-serous suture and continue with that until the per- 
forating sutures are completely buried; or, in other words, until the 
sero-serous suture has traveled completely around the bowel and the 
terminal thread knotted with the primary suture. 

If preferred, this sero-serous suture maybe an interrupted instead of a 
continuous stitch (Fig. 412), but the continuous suture is more rapidly 



TECHNIQUE OF TERMINO-LATERAL ANASTOMOSIS. 



529 



passed and is in every respect as secure. The main thing to be at- 
tained, however, is that the serous surfaces be brought into contact 
through the whole circumference of the bowel. 

Fig. 413 shows the appearance of the bowel on cross section after 
such an anastomosis. This method may be modified in many ways but 





Fig. 414. — Termino-lateral anastomosis. 
Clamps and continuous suture employed. 
(Binnie.) 



Fig. 415. — Termino-latera 
anastomosis completed. 
(Binnie.) 



exemplifies, really, the fundamental principles involved in any anas- 
tomosis of the digestive tube. It is purposely stated in its simplest 
terms and shorn of detail. 

The technique of the termino-lateral form of anastomosis does not 
differ in any essential detail from that just described for the latero- 
lateral form (Figs. 414 and 415). 



34 



CHAPTER XIV. 
IMPERFORATE ANUS. 

A correspondent addresses the editor of the Journal of the American 
Medical Association (September 8, 1906) to this effect: 

"Mrs. B., a perfectly healthy woman of twenty-eight years of age, 
after a normal pregnancy, gave birth to a fine eight pound boy, well 
nourished and healthy looking and perfect in every way except there 
was no anus nor sign of any. A small amount of meconium was being 
passed through the urethra. The next morning a local surgeon was 
called in counsel and an incision was made through the floor of the 
pelvis and dissected up along the coccyx, but no rectum was found 
nor trace of a gut until the sigmoid flexure was reached in the free 
peritoneal cavity. A large opening in the sigmoid was followed by 
a discharge of feces. No attempt was made to stitch the gut to the 
wall or the integument. The opening w^as not closed in any way and 
no dressing applied, except that the nurse was directed to keep the 
site of the operation sponged with a saturated solution of boracic 
acid after each evacuation of the bowels. The child nursed well after 
the operation and has continued to do so. It sleeps nearly all the 
time but has had no elevation of temperature; the passages come 
free and the urine is passed normally. Can you suggest any means 
of treatment that will permit the child to grow up with at least a slight 
control of bowel movement?" 

That is the question which occurs to every doctor compelled to 
deal with these cases, which are fortunately rare. The little being's 
life rests upon the doctor's readiness to act; and if it survives, whether 
or not it carries a life-long disability depends largely upon his skill. 

It usually happens in the course of such cases that no meconium 
passes within a reasonable time after the baby's birth. It grows 
restless, perhaps vomits, and for the first time it is suspected that there 
it some abnormality about the rectum or anus, which an examination 

530 



OPERATION FOR IMPERFORATE ANUS. 



531 



verifies. It is imperative to relieve the condition at once and if no 
specialist is within reach, the doctor must undertake it. He may 
find it quite easy, or he may find it impossible. 

In the first instance, the anus and rectum may be both fully devel- 
oped, but in passing a finger or probe into the orifice, a thin bulging 
membrane can be felt, apparently almost ready to burst when the 
infant cries. A sharp-pointed bistoury, wrapped and introduced 
along the finger or a grooved director, easily punctures the membrane, 
follow^ed by a free passage of meconium; and thereafter the bowel 




Fig. 416. — Incision for imperforate auus. (Veau.) 



readily empties itself. The mother is directed to dilate the opening 
daily with her little finger, and that, with an occasional stretching 
with a bougie, is sufficient. 

In another case there may be no depression where the anus should 
be. The median raphe extends unbroken from the scrotum to the 
coccyx. The anus is absent and it may be practically impossible 
to tell how high up in the pelvic cavity the rectal cul-de-sac may be; 
and yet it is one's duty to hunt for it through the perineum. 

Operation. — ^Put the patient on its back with thighs flexed and 
pelvis elevated, in short, in the lithotomy position. Employ a light 
chloroform anesthesia, not that there is any danger if the anesthesia 



532 



IMPERFORATE ANUS. 



is carefully conducted, unless indeed, the operation has been too long 
delayed, but that a little straining on the patient's part may help to 
locate the bowel. 

Make a median incision from the base of the scrotum or from near 
the posterior vaginal wall to the coccyx, which must be exposed (Fig. 
416). A number of eventualities may present. 

(i) One may find immediately beneath the skin some of the fibers 
of the external sphincter, a favorable indication. Split these fibers 
by blunt dissection. Free incision may spoil their usefulness. Be- 




FiG. 417. — Retention suture. (Veau.) 



neath the muscular layer appears the lobulated fatty tissue peculiar 
to the new-born, which is to be next divided. Here one must go 
slowly, keeping in the middle line and all the time working toward 
the coccyx. The danger is in front. If toward the hollow of the 
sacrum, a fluctuating pouch is felt or a brownish rounded tumor is 
seen, one breathes easy, knowing that the imperforate gut is within 
reach. But do not be in a hurry to open the gut. It is first to be 
secured by passing a suture on each side of the middle line or by 
catching the bowel wall with forceps. The suture. should not per- 
forate the bowel. 

Making gentle traction on the bowel, proceed to free it by careful 
blunt dissection. Do not use knife or scissors to divide what seem 



OPERATION FOR IMPERFORATE ANUS. 



533 



to be fibrous bands, for it is possible they contain the blood supply 
of the bowel; and if divided, dangerous bleeding may occur or the 
tissues become gangrenous. 

As the pouch is freed, it is gradually pulled down into the wound; 
and if they were not passed before, two sutures are now passed with 
which eventually to fasten the gut to the skin opening (Fig. 417). 
Now is the time to open the pouch and let the meconium flow out. 
It may require several minutes for the bowel to empty itself. Evert 
the mucous membrane, 'enlarging the bowel wound a little if necessary. 




Fig. 418. — Muco-cutaneous suture. (Veau.) 



Suture the mucous membrane directly to the skin; no other tissues 
should intervene (Fig. 418). 

Irrigate thoroughly and apply a gauze dressing, which is changed 
as often as soiled. The functional result is often surprisingly good. 
Broncho-pneumonia may develop when the operation has been too 
long delayed and -septic absorption has begun. 

(2) The pouch cannot he drawn down. In that case when the bowel 
is opened the discharge will have to flow over the raw surfaces of the 
flesh wound which will need to be kept open with bougies. Infection 
is a constant danger, not to speak of lack of control of bowel movement. 

Better than to leave the wound in this condition, the coccyx and a 
part of the sacrum mav be removed and I lie gut brought out poste- 



534 IMPERFORATE ANUS. 

riorly. Still better, open the peritoneal cavity, find and draw down 
a loop of the sigmoid to fasten in the wound. 

(3) The pouch cannot he jound. Obtain more room by resecting 
the coccyx, follow the sacrum a little higher, open the peritoneal cavity 
and search for the cul-de-sac ; if possible, draw it down into the wound 
and suture. 

If all these measures fail, there is nothing to do but make an artificial 
anus in the inguinal region. Indeed, there are those who advise this 
from the first with the idea that later the operation for the construction 
of a normal anal orifice can be better undertaken. 

Tuttle says (Diseases of the Anus, Rectum and Pelvic Colon) that 
where there is no evidence that the rectal pouch can be easily reached, 
and where the child is in an enfeebled condition with distended 
abdomen, fecal vomiting, and nausea in progress, one should not 
hesitate to choose the abdominal route, perform an inguinal colotomy 
at once and thus afford an immediate exit to the intestinal contents, 
and an escape for the gases which are causing the distention and 
the constitutional disturbance. 

To this same volume the reader is referred for a full discussion of 
these problems, and for consideration of those other forms of imper- 
fect development in which the anus has abnormal openings. Such 
cases are not strictly emergencies for usually there is a partial means 
of escape for the bowel contents. 



CHAPTER XV. 

TORSION OF THE PEDICLE OF OVARIAN OR UTERINE 
TUMORS ; OF THE SPERMATIC CORD ; OF THE PEDI- 
CLE OF THE SPLEEN ; OF THE OMENTUM. 

Torsion of the pedicle of an ovarian or uterine tumor may be either 
chronic or acute; in the one case developing so slowly as to produce 
no symptoms or even no effect upon the tumor unless merely to in- 
hibit its growth, for in the adhesions are new sources of nutrition; 
in the second case developing suddenly and producing a train of 
symptoms that demand immediate relief. The acute cases alone, 
then, are to be regarded as em.ergencies. 

Cysts of the ovary, especially those which are spherical, non-adherent 
and connected by a long pedicle, are most liable to this accident. 

Kelly finds two causes for this rotation. The first of these is in the 
effort of a large cyst to accommodate its convex surface to the con- 
cavity of the distended anterior abdominal wall. The second cause 
is found in contractions of the anterior abdominal wall, which act 
upon the part of the tumor nearest the middle line. The effect of 
the force thus applied is to rotate the tumor. In the case of smaller 
tumors lying in the pelvic cavity, it is likely that unusual movement 
in the intestine, or readjustments of the pelvic viscera, may produce 
the same effect. Kelly quotes Kustner to the effect that tumors of 
the right side, as a rule, rotate from left to right, while left ovarian 
tumors rotate from right to left. 

The diagnosis of acute torsion is not difficult if an ovarian cyst is 
known to be present. If such a tumor w^as previously unsuspected 
the certain diagnosis may be impossible, c^^pecially if the case is seen 
late and general peritonitis is developing. 

The symptoms, as a rule, arise without warning. There are severe 
colicky pain, vomiting, marked constipation and the appearances of 
collapse. Abdominal rigidity and tension ra})idly increase. This is 

535 



536 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS. 

true of the more urgent cases. In general the severity of the symp- 
toms vary with the degree of torsion. 

Appendicitis and acute intestinal obstruction present the greatest 
difficulties in differential diagnosis which it is desirable to make, not 
to determine the advisability of operating but to determine before 
hand the kind of operation one is to undertake. Ranzi (Berliner 
Klin. Wochenschrift, Jan. 6, 1908) reports four cases of torsion of 
ovarian cyst which were not differentiated from appendicitis, except 
in one case, before the operation and in this case by the pains in urin- 
ating. In three of the cases there had evidently been mild attacks 
of torsion which had subsided and which had been diagnosed as 
catarrhal appendicitis. 

The treatment is operative. And as has been indicated, the operation 
must often begin as an exploratory laparotomy, for though the symp- 
toms indicate the seriousness of the case they may not reveal its 
character. Delay is dangerous in these cases and seldom will one 
regret having operated early, for nearly always the lesions found 
exceed the expectation. 

The appearances once the abdomen is opened will depend upon the 
size of the tumor, the degree of torsion and the time of intervention. 
Usually the tumor will be found enveloped in loops of intestine 
bound together by soft adhesions (Fig. 419). 

These adhesions are to be carefully separated, and one must proceed 
with prudence for the cyst may be filled with pus and its walls may be 
friable. The intestines, detached, are to be held out of the way with 
compresses and the tumor thus brought into view. Its nature may be 
at once apparent in spite of the fact that it is discolored, daik red, or 
even black. If it is a cyst not quite so large, it may resemble a dilated 
cecum. Its attachments are carefully broken up and gradually 
woiking towards its base the pedicle is finally defined. 

An effort is now made to lift the tumor out of the abdominal cavity, 
and there need be no hesitancy in enlarging the abdominal incision 
if necessary. Usually it is to be lifted out with the two hands applied 
to its base. Occasionally only after its pedicle it untwisted is it 
possible to deliver it. 

Next the pedicle is tied near its point of implantation, divided, 



TORSION OF UTERINE FIBROIDS. 



537 



and thus the tumor is removed. If there are no evidences of infection 
the abdomen is to be closed without drainage. 

Tumors springing from the uterus are much less likely to become 
twisted. Yet, in the case of large non-pedunculated fibroids, the 




Fig. 419. — Torsion of the pedicle of an ovarian cyst. (Montgomery.) 



uterus itself may be rotated and give rise to symptoms which demand 
relief. In such a case the intervention may be quite complex. 

In some instances a myomectomy may be sufficient. The uterine 
wall is incised over the long axis of the tumor, which is exposed and 



538 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS. 

peeled out, and the hemorrhage checked by suture of the uterine 
wound. The uterus may still tend to rotate and may require fixation. 

In still other instances, hysterectomy, either supra-vaginal or 
complete, may be the procedure necessary for relief. This will be 
the case when the condition of the uterine wall after removal of the 
tumor would preclude repair. 

Harsha reports to the Chicago Medical Society (Annals of Surgery, 
Nov., 1905J a case of torsion of the pedicle of an ovarian cyst in a 
woman of ^^, who for several years at intervals had had attacks of 
intestinal obstruction, accompanied by pain and vomitingj lasting for 

3 or 4 days. 

Her last attack began suddenly with pain, vomiting, constipation, 
tenesmus, accompanied by the symptoms of shock. At the end of 

4 days the abdomen was opened. A cyst, the size of an orange, with 
twisted pedicle was removed.. There was neither peritonitis nor 
gangrene. There had been no further indications of obstruction. 

In a secgnd case the cyst w^as as large as a fetal head and black to 
within an inch of its implantation. 

Oschner, commenting on these cases, says that symptoms of ob- 
struction are not uncommon in such cases and that the history is 
often that of volvulus. 

He cites a case in which the abdomen had been opened by a prac- 
titioner who believed he was dealing with intestinal obstruction. 
Having opened the abdomen, however, he discovered a large black 
tumor. Disconcerted, he stopped his operation, hurriedly trans- 
ported the patient to the Augustana Hospital where Oschner com- 
pleted the work. 

The doctor performing an emergency laparotomy must not have 
his mind too definitely fixed on one diagnosis. Expecting one thing 
he must still have in view the possibility of having to deal with one or 
more of a variety of conditions, and so will not be taken completely 
unaware. 

John CahU] and Sir William Bennett give the history of a case which 
well exemplifies the difficulties of diagnosis, the occasional complexity 
of treatment and the dangers of delay. (London Lancet, Dec. 8, 
1906.) 



TORSION OF THE SPERMATIC CORD. 539 

The patient, aged 17, was suddenly seized with abdominal pain. 
There was some tenderness and resistance over the right iliac fossa. 
The temperature was 98.8, the pulse 90. Bowels were emptied by 
enemata but the pain continued. On the third day the temperature 
ran up to 101.8 and the pulse to 120. 

An operation was still refused until at the end of a wxek the patient's 
condition had become very grave. An operation for appendicitis 
was then performed and the appendix found adherent and filled with 
pus, in addition to other evidences of chronic disease. Further 
examination revealed a dark, firm mass occupying the upper part of 
pelvic cavity and intimately adherent to the bladder and uterus. 
Exposed by extending the incision, it proved to be an ovarian cyst the 
size of a cocoanut with a thick pedicle twisted upon itself for three- 
fourths of a turn. Its walls were thin and blackish and its contents 
mainly decomposed blood. The cyst was removed and the patient 
recovered. 

Dr. Cahill, commenting on the case, remarked that the situation 
of the cyst was unusual in that it was wedged between the bladder and 
uterus, whereas one expects to find such a tumor in Douglass' pouch. 

Sir William Bennett says that although cases not infrequently 
operated upon for appendicitis prove to be cases of torsion, yet the 
coexistence of the two conditions must be very rare. He suggests 
that in this case the appendicitis, by aggravating the intestinal peris- 
talsis, had displaced the tumor with consequent torsion of its pedicle. 

Angus (British Medical Journal, Jan. 27, 1906) reports an attack 
in a child of six, beginning with pain, vomiting and abdominal dis- 
tention. By the rectum a mass was palpable in the cul-de-sac. A 
diagnosis of appendicitis with abscess formation was made. Opera- 
tion. The appendix was inflamed at the end where it was attached 
to a dark cystic swelling in Douglass' pouch. It was the right ovary 
darkly congested, large as a duck's egg, and with twisted pedicle. 
Its contents showed it to be an ovarian dermoid. 

TORSION OF THE SPERMATIC CORD. 

Malformations and imperfect descent predispose to rotations of 
the testicle— an accident rare yet none the less to be borne in mind 



540 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS. 

as a possibility. The exciting cause is usually to be found in trauma. 
A heavy lift or strain may produce it. 

It is readily comprehended that an incompletely descended testicle 
shifting backwards and forth through the external ring could be 
forcibly rotated. The rotation may occur in two ways; either the 
testicle with its tunica vaginalis may be turned, or the testicle alone 
may rotate. The spermatic vessels, nerves and the vas deferens are 
all involved in the resulting torsion. 

The symptoms range from moderately severe to grave. Pain, 
nausea, vomiting, constipation and tympanites signalize the attack 
and soon the signs of local inflammation appear. 

In the more serious cases the pain begins abruptly and persists. 
It usually radiates from the inguinal region and lower part of the 
abdomen and may be intense or even produce shock. The con- 
stipation is usually relieved by enemata. 

The presence of a painful tumor in the inguinal region together with 
the symptoms point to strangulated hernia and torsion of the sper- 
matic cord equally, and the differential diagnosis may be a matter of 
difi&culty. The pain is much more intense and sudden in its onset 
than epididymitis. The cord, in torsion, can be felt tender and swollen ; 
it cannot be felt in strangulated hernia. Of course in strangulated 
hernia the constipation is absolute. 

Once the diagnosis is assured an effort to untwist the cord should 
be made and occasionally it will succeed. It is recorded of patients, 
who, having had several attacks, learn to give themselves relief. If 
manipulation fails it is imperative to operate without delay for there 
is danger of gangrene of the testicle. 

An incision extending from near the external ring follows the cord 
down toward the base of the scrotum. Layer by layer the tissues 
are divided until the tunica vaginalis is reached. The tissues are often 
edematous, reddened and swollen. The tunica presents itself as 
a thin-walled sack. Open it and drain away the serum and the testicle 
will be found, possibly deformed, perhaps difficult to recognize, and 
above it is the twisted cord. 

Seize the testicle and rotate it from right to left in order to relieve 
the torsion and restore the circulation. The further procedure will 



TORSION OF THE PEDICLE OF THE SPLEEN. 54 1 

depend upon the integrity of the testicle. If its violet color fades, 
if the congestion diminishes, it is almost certain the testicle will recover 
and is therefore to be preserved. If it is black, or mottled, or flaky 
remove it by tying the cord above the torsion (see castration). If its 
integrity is doubtful, preserve the testicle but provide ample drainage 
for the tunica vaginalis. 

Lichtenstern, of Vienna, reports a case of torsion of the spermatic 
cord in a man of 46, which began with lifting a heavy load. The 
scrotum soon became enlarged and vomiting and constipation ensued. 
A diagnosis of inguinal hernia had been made and efforts to reduce 
had failed. 

At the time of entrance at the hospital his temperature had reached 
102 and his pulse was bad. In the scrotum w^as a large, tense tumor 
and in the inguinal canal another smaller. 

On opening the scrotum an enormously swollen, turgid testicle 
was found whose spermatic cord w^as twisted to 360 degrees. Part 
of the omentum was found at the internal ring. The testicle was 
untwisted and removed, the cord resected and the inguinal canal 
closed as in herniotomy. 

TORSION OF THE PEDICLE OF THE SPLEEN. 

The pedicle of the spleen may become twisted in cases of wandering 
spleen. As in other varieties of torsion it may develop slowly, pro- 
ducing no marked symptoms and resulting only in congestion of the 
organ and increase in size. Developing suddenly it is accompanied 
by the symptoms of general peritonitis or intestinal obstruction, and 
collapse. It may be mistaken for one of these conditions. The 
tumor may suggest subphrenic abscess. 

As Moynihan says, in the great majority of cases, splenectomy 
is the better course to pursue and this is especially true when throm- 
bosis of the splenic vessels, infarcts in the spleen, gangrene or perit- 
onitis upon or around the spleen are present; when also the organ is 
enlarged it should be removed for even though the pedicle be untwisted 
it is useless to try a splenopexy. 

The result of fastening in place a small wandering spleen is doubtful. 
If it is enlarged, failure is certain. Fortunately, as Hartmann has 
pointed out, a displaced spleen is usually not at all diflicult to remove 



542 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS. 

because the lengthened pedicle permits of ready delivery; and the 
after-effects are not so serious as those which attend removal for 
organic disease. 

TORSION OF THE OMENTUM. 

Torsion of the omentum must naturally be a rare condition and 
yet is to be thought of when symptoms of intestinal obstruction arise 
in those who have a hernia or are obese. 

Torsion of the omentum is naturally painful. The pain, which is 
probably due to the plugging of the omental vessels, may simulate 
appendicitis. It is not important that the differential diagnosis is 
sometimes not made, for the symptoms indicate operation. 

Rinchea and Corner describe a case in the British Medical Journal, 
Jan. 20, 1906. The patient, a man of 48, had had a hernia for 37 
years and had worn a truss for t,t,', the hernia had been reducible 
and painless. He was suddenly seized with pain and the hernia 
became irreducible. The pain increased, and the tumor as well, 
though after two days the bowels moved, a circumstance which ruled 
out strangulated hernia. The temperature remained 99, the pulse 
102. The skin over the lower part of the abdomen and inguinal 
region became reddened and the region tender. An incision over 
the inguinal canal found the tissues inflamed, and on opening the 
hernial sac a small mass of omentum was found twisted on itself five 
times but not constricted at the internal ring. The mass was resected 
and the radical operation for hernia performed. 

In another case, the patient, a man of 45 with recent direct hernia, 
a mass of omentum was found, pedunculated, the size of a walnut 
and containing a hemorrhagic cyst. 

Cullen, of Baltimore (Johns Hopkins Hospital Bulletin, Dec, 
1905), reports a case occurring in a very heavy man. The patient, 
a railway conductor, had found it necessary to eject a recalcitrant 
passenger and succeeded only after a struggle. In a few hours he 
had developed the symptoms of appendicitis. 

At the operation a gray, vascular, nodulated mass was found which 
ended above in a tightly twisted pedicle and which on removal proved 
to be the omentum. 



CHAPTER XVI. 

RUPTURE AND HEMORRHAGE OF TUBAL PREG- 
NANCY. 

Rupture of the sac of an ectopic gestation is far from being a rare 
accident (Fig. 420). When it occurs, it is a major emergency, one in 
which the doctor, isolated though he may be, must act and without 
delay. Eighty-five per cent of these cases operated upon, recover; 
eighty-five per cent of those treated by expectancy, die. These figures 
are in themselves sufficient argument, but when we add that the gravity 




Fig. 



420. — Ruptured tubal pregnancy. Clot protruding from sac. (Montgomery.) 



of the condition grows out of hemorrhage, the reason for immediate in- 
tervention must be admitted by all. 

That the diagnosis of an extra-uterine pregnancy even when 
suspected, is difiicult, no one will deny. After the most careful exam- 
ination, one may not avoid error. More often, the condition is not 
even suspected until rupture occurs. 

A tubal pregnancy may be unrecognized, but there can be 110 excuse 
for overlooking a ruptured tubal pregnancy. It can scarcely be mis- 

543 



544 RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY. 

taken for anything else. Even if we admit that exact diagnosis may 
be impossible, yet the indications for intervention are unmistakable. 
And that, after all, is the important thing. One does not do grave 
emergency operations on mere impressions or suspicions, or the fear 
that such and such may be the case. 

The attack comes on suddenly. There are pain, shock from the 
peritoneal tear, and vomiting, suggestive of actue intestinal obstruction. 
One might also think of a renal calculus. There is often a bloody 
uterine discharge. The history of the case and, finally, the signs of 
progressive internal hemorrhage point to the nature of the accident. 
The pulse grows more rapid and feeble, the temperature falls, the 
features are blanched, dyspnea appears and all the symptoms of 
collapse. Vaginal examination completes the diagnosis. One may 
find the uterus but little enlarged, but on one side or the other, rising 
out of the retro-uterine pouch, a boggy mass of variable size is felt. 
Dixon, of St. Louis (Interstate Medical Journal), says that in fifteen 
cases, he found the pregnancy on the right side in all but one, and this 
patient had the peculiar fortune to have one on both sides. The right 
side was relieved by operation, and six months later the left side neces- 
sitated a second operation. Dixon adds that rigidity of the abdom- 
inal walls was present in most of these cases, though the absence of 
rigidity is often named as a differential diagnostic point. 

There may be an element of confusion. Vineberg, of New York 
(New York Med. Jour., Feb. 22, 1906;, reports two cases out of his 
fifty-three in which there was a combined intra- and extra-uterine preg- 
nancy. He notes that a persistence of uterine bleeding after an opera- 
tion for extra-uterine pregnancy, should suggest the possibility of an 
intra- uterine gestation. He adds, with respect to diagnosis of the con- 
dition generally, that amenorrhea, followed later by pain and irregular 
uterine bleeding, should always put one on his guard. 

From the history, then, and from the physical examination, one must 
diagnose the condition. On the signs of progressive internal hemorrhage 
the decision to operate immediately, is based, and one should scarcely 
ever deem it too late, for even in the face of the most menacing condi- 
tions, we must hold bravely to the last resource in which, even in the 
desperate cases, there is often safety and life. 



OPERATION FOR RUPTURE IN TUBAL PREGNANCY. 



545 



Operation.— As Lejars says, the operation is moving and dramatic, 
but presents no especial difficulties if one but keeps cool and knows 
what is to be done. 

Instruments. — The instruments necessary are scalpel, scissors, artery 
forceps, two long clamp forceps, two retractors, and curved needles. 

General Anesthesia. — General anesthesia is necessary and must be 
closely watched. A continual hypodermoclysis is an excellent means 




Fig. 421. — Forceps applied to the tubo-ovaiian pedicle, 
Trendelenburg position. (Veau.) 



of combating the combined effects of shock and anesthesia. It should 
not be begun, however, until the hemorrhage has been controlled. 

Antisepsis. — It is scarcely necessary to say that it is of little use to 
save the patient from hemorrhage to die a few days later from 
sepsis. The peritoneal cavity, under the conditions assumed, is a 
dangerous culture medium. 

The Trendelenburg position is almost indispensable, and if necessary, 
may be improvised. 
35 



546 



RUPTURE AND HEMORRHAGE OP TUBAL PREGNANCY. 



Incision. — A median incision extending from the umbilicus toward the 
pubes is made. Do not wound the bladder, which may be pushed up- 
ward and forward. This, however, is not particularly serious unless the 
wound should be large or overlooked. Waste no time. As soon as the 
peritoneum is opened, catch its edges with artery forceps and enlarge the 
orifice upward and downward. Do not try to sponge out the cavity. 
Without regarding the clots, which will roll out and which mask the 
viscera, plunge a hand into the pelvic cavity and locate the uterus, which 




Fig. 422. — First ligature applied. (Veau.) 



is easily recognized. To one side, a thick, doughy or friable mass will 
be felt. Slip your fingers under it, break the adhesions, and enucleate 
it. This will empty the retro-uterine pouch — the cul-de-sac of Doug- 
lass. Feel with finger and thumb for the pedicle and, if possible, pull 
the entire mass up into the wound and clamp. If the mass is not 
adherent, a single clamp enclosing the broad ligament from the outer 
side and passing under to include the tube will suffice (Fig. 421). 
If there is too much adhesion, clamp on either side of the pedicle. 
When the clamps are placed, the chief end of the operation has been 



LIGATION OF THE PEDICLE. 



547 



attained. Do not waste time trying to catch the bleeding points, but 
ligate en masse. 

Ligate the Pedicle. With a blunt, curved needle armed with No. 3 
catgut, transfix the pedicle close to the cornu of the uterus, between it 
and the forceps (Fig. 422). Ligate and then carry the ligature around 
the lower segment of the pedicle and tie again, directing the assistant 
to pull up on the clamp, and finally carry the ligature around the entire 
mass and tie a third time. Preserve the ends of the ligature. Resect 




Fig. 423. — Ligation and division of the tubo-ovarian pedicle. (Veau.) 



the tumor and lift up the stump by means of the threads to see if 
there is any bleeding (Fig. 423). This ligature stands between the 
patient and death. If two clamps have been used, it will be necessary 
to ligate "enchaine." 

Now clean out the clots, mop out the blood, and lower the pelvis to 
drain the upper part of the abdominal cavity. The quantity of blood 
is often enormous. If the patient is very weak, do not prolong the 
task of cleansing it all out; yet in the long run, it is better to take the 



548 RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY. 

time to cleanse out the fossae and wipe the intestine and omentum, for 
then the abdomen may be closed without drainage. 

Drainage. If there is oozing, apply a gauze drain at the site of the 
tumor, and insert three or four drainage tubes into different parts 
of the cavity to carry out the blood left behind. Do not forget to fix 
the drains, lest they be lost in the abdomen. 

Suture the wound partially^ unless able to dispense with drainage, in 
in which case suture completely. Apply a dry dressing of gauze and 
absorbent cotton. Inject salt solution. After twelve hours, change 
the dressing , which will probably be saturated; thereafter change daily. 
About the seventh day the tubes may be shortened, and about the fif- 
teenth day or often sooner altogether removed. 






Fig. 424. — Tubo-ovarian pregnancy. (Montgomery.) 

Interstitial tubal pregnancy (Fig. 424) may occasionally be met with and 
present complications. A case described by O. G. Pfaff, of Indianap- 
olis (Western Clinical Recorder, March, 1903) illustrates the subject. 
On opening the abdomen a large reddish bag presented, which seemed 
to develop from the right wall of the uterus, involving the right tube. 
In order to minimize the hemorrhage as well as to secure the tumor, 
the upper portion of the broad ligament was clamped and another 
clamp placed to the left of the tumor passing obliquely across the fun- 
dus and including the uterine artery. The sac was now incised at its 
summit and the fetus, membranes, and placenta turned out. No 
ligatures were required. The sac was partially sutured, a drainage 



HYSTERECTOMY FOR HEMORRHAGE. 549 

tube fastened in its cavity and brought out through the lower angle of 
the abdominal wound. The drainage tube was removed on the fifth 
day, and recovery was complete. 

Hunt (British Medical Journal, Sept. 29, 1906) reports a similar 
case operated on after rupture and the hemorrhage was only controlled 
after hysterectomy. In some cases, perhaps, as Lejars indicates, ex- 
cision of a "V" shaped section from the region of the cornua with sub- 
sequent suture will succeed. 



CHAPTER XVII. 
CESAREAN SECTION. 

Cesarean section, designed primarily as an operation to save the babe 
after the mother's death, is today of far broader application. Without 
considering its exact indications, which for that matter the whole pro- 
fession is not yet agreed upon, it may be stated broadly that it is the 
method of choice when the child cannot otherwise be delivered alive. 
Unfortunately at the present time it is usually what it should not be 
viz., an emergency operation. 

The Technique of Operation. First Stage: Laparotomy. — Incise 
the abdominal wall. The incision extends in the middle line to within 
2 inches of the pubes and should be at least 4 inches in length. If the 
uterus is to be brought out of the abdominal wound it will require to 
be longer. The peritoneum is to be exposed and opened up in the 
usual manner. The abdominal walls are often quite thin. As soon 
as the peritoneum is opened the uterus pushes into view. Correct 
any lateral deviation. Hurriedly wall off the uterus with sterile com- 
presses, or deliver the uterus, protect with sterile compresses and suture 
the upper angle of the peritoneal wound. 

Second Stage: Incision oj the Uterus. — Keep exactly in the middle 
line. Make a small incision in the uterus at the level of the lower end 
of the abdominal wound that you may not later encroach upon the 
lower segment of the uterus. 

The peritoneum and superficial muscular layers are divided with 
the bistoury, the deeper muscular fibers separated with the fingers. 
Make a small opening in the mucous membrane. Through this wound 
slip a finger into the uterus and on it as a guide divide the uterine 
wall with scissors toward the summit; the incision should be 6 or 7 
inches long. If the placenta is attached over the median line, cut 
through it also. It makes no difference if the work is done rapidly. 

Third Stage: Deliver the Child. — Slip the hand into the uterus. 
Grasp the feet, delivering the breech first. Clamp the cord in two 
places and cut between. 

550 



CESAREAN SECTION. 55 1 

Fourth Stage: Remove the Membranes. — As soon as the child is 
delivered the uterus contracts and often the placenta is detached at 
once. If not it must be peeled off with the fingers. 

Fijth Stage : Suture the Uterus. — Repair the uterine wall with 7 or 8 
interrupted catgut sutures deeply placed but not reaching the mucosa; 
or suture the mucosa first. Complete the repair by a few superficial 
sutures. Suture is the best means of hemostasis, but the bleeding is 
usually inconsiderable, especially if the uterus is brought outside and 
bent toward the pubes. 

Sixth Stage: Suture the Abdominal Wall. — Repair the peritoneum 
with continuous catgut suture; the fascias with chromic gut or plain 
catgut; the skin with silkwormgut. 

These are the principles involved, bared of details which, of course, 
vary with the operator and with the environment. Examples are not 
wanting in current literature. A few will serve to bring out practical 
points. 

Lanphear, of St. Louis (American Jour. Surgery, Dec, 1906), formu- 
lates a technique for country practice. The operator should have a 
physician for assistant, or a trained nurse. The anesthetic should be 
given by a physician. 

Instruments. — Vaginal retractor (for cleansing the vagina), knife, 
scissors, 4 hemostats, needles, chromic catgut No. 2, silkwormgut, 
safety pins. 

The containers for the solutions must be boiled and singed with 
burning alcohol — one for bichloride, i to 2000, one for alcohol, and 
one for sterile water, a small dish or two for the instruments. 

Dressing and Sponges. — Boil 15 yards of gauze and 12 towels free 
from fringes. 

Preparation of Patient. — Pubes and vulva shaved. Abdomen 
scrubbed. When the anesthesia is complete scrub the vagina with 
gauze and soap and water, followed by alcohol. 

Preparation of the Hands. — They are to be scrubbed for 5 minutes 
before disinfecting the patient and for 5 minutes after, followed by 
immersion in alcohol and then in the bichloride solution. Again sponge 
the abdomen before covering the field with four sterile towels fastened 
with sterile safety pins. 



552 CESAREAN SECTION. 

Abdominal Incision. — Deliver the uterus and surround with four 
towels wrung out of very hot water. Protect the edges of the wound 
with sterile towels packed in around the uterus. 

Incise the uterus; deliver the child; clamp and cut the cord. The 
anesthetist may now look after the child if there is no one else to do 
so. Be careful in handling the child that your hands do not come 
in contact with anything not sterile. Deliver the placenta, mop 
out the uterus; suture. Lanphear advises a final row of Lembert 
sutures for the .peritoneal covering of the uterus. Repair the ab- 
dominal wall; dress as usual; pack the vagina lightly and treat sub- 
sequently as after any other confinement. Brown, of Manchester, N. 
H., recommends practically the same procedure. (Americal Jour. 
Surgery, Feb., 1907.) He observes that the uterus should be kneaded 
for a moment to stimulate contraction. He uses in suturing the uterine 
wall, a row of 20-day chromicized gut sutures, passing through all 
the layers, a second row of Lembert sutures of silk. 

Paul Martin, of Indianapolis, reports a case (Medical Record, Oct. 
27, 1906). Operated. after 12 hours of labor complicated by eclamp- 
sia and a narrow pelvis and in which the bladder was greatly distended 
and which could not be emptied by catheter. The bladder extended 
half way to the umbilicus. The uterus was emptied through a 4 inch 
incision and the bleeding controlled by the assistant who grasped the 
cervix. The uterine sutures employed by Martin were a double row 
of interrupted muscular sutures of chromic gut and a continuous 
chromic gut for the serous coat. The bladder was not injured and 
afterwards easily emptied. Mother and child both survived. 

T. B. Noble, of Indianapolis, reports a case operated on the same day 
as Martin's. Noble's operation was deliberately planned. He 
waited until labor was well under way and operated with an entirely 
satisfactory result. 

Walker Schell, of Terre Haute (Indiana Medical Journal, Dec, 
1906), by section delivered safely a 200 pound mother of a 11 J lb. babe 
after a three days labor. In two minutes from the commencement of 
the operation the babe was in the hands of the nurse. Schell closes 
the uterus with interrupted silk and continuous catgut suture. 

Kolmer and Anderson, of Indianapolis (Indiana Medical Journal 



CESAREAN SECTION. 553 

March, 1907) describe an operation. The bleeding was readily con- 
trolled by hot gauze pads. The uterine incision 6 inches long. Re- 
pair of uterus: (i) Continuous suture through muscle and mucosa 
with No. I Van Horn plain gut; (2) continuous suture through muscle, 
No. 2 Van Horn plain gut; (3) muscle and peritoneum. No. 2 chromi- 
cised; (4) peritoneum with No. i silk. Patient up on the twelfth day 
without inconvenience. Kolmer remarks that the general practitioner 
should make his patients who may need the operation acquainted with 
its nature and success and so enlarge the domain of the profession's 
benevolence. 

S. A. Reynolds (Gaillards Southern Medicine, Feb., 1905) reports an 
operation which as he says illustrates the principle that we should never 
be afraid to put forth an effort to relieve our patients when absolutely 
demanded, however hazardous and difficult the intervention and 
however meager the means at our command. Place, a log cabin with 
one room, lighted by a lamp without chimney. Patient, a colored 
girl of 13 with pelvic diameters less than 2 inches; labor for 12 hours 
with a midwife in attendance. Both he and Dr. Keen with whom he 
consulted realized the urgency but neither had ever done a laparotomy. 
Their equipment consisted of two pocket cases of instruments, carbolic 
acid, a few ligatures, an earthen pitcher and bowl with tea kettle of hot 
water. They sterilized their instruments and hands in carbolic 
solution. Patient was laid across the bed with feet on the floor. 
The abdomen washed. AVhile Dr. Keen gave the chloroform Reynolds 
made an incision from the umbilicus down. The sides of the abdomen 
were pressed against the sides of the uterus to prevent bleeding into the 
abdominal cavity, and the uterus opened and emptied. 

One suture was put in the uterus. Abdominal wall closed with 
silk. On the fourth day the temperature was 103.5, P^ilse 150, resp. 
36, but the symptoms of infection subsided and by the fourth week 
the patient was well. 

Schaute's clinic with a record of 175 cases furnishes the conclusion 
that the ultimate outcome of these operations is still far from perfect 
and that the best results are obtained from a sagittal incision of the 
uterus made as high as possible. 



CHAPTER XVIIT. 
RUPTURE OF THE URETHRA.* 

By a fall astride a hard or sharp margined object, by accidents of 
saddle or bicycle, by a kick or blow, by a fracture of the pelvis, the 
urethra may be ruptured. The urethral canal is forced up against the 
pubic arch or against the sharp edge of the triangular ligament, and is 
lacerated while the more elastic integument of the perineum escapes. 

Any part of the urethra may suffer, although usually only one part 
is involved in a given case. The prognosis, and in some degree the 
treatment, depend upon the portion injured, though the exact location 
is not always easily determined. 

Again the prognosis and treatment depend upon whether the rupture 
is total or incomplete, for upon the degiee of laceration depend the 
rapidity of extravasation and later the dimensions of the stricture. 

These, then, are the dangers — extravasation of urine, and in its wake 
suppuration, abscess formation and general septic infection; on the 
other hand and later, stricture formation and all its attendant diffi- 
culties. 

*"We consider it unnecessary to speak of the medical treatment which is abso- 
lutely valueless and while the mechanical treatment has been in favor even with 
the surgeon, it must be condemned if it becomes a general procedure. 

The introduction of sounds and catheters into a lacerated urethra, will almost 
invariably be followed by infection at the point of laceration, notwithstanding the 
aseptic conditions under which the catheterization is performed. The general 
practitioner has been accused of inefi&ciency and carelessness in sterilizing his in- 
struments. While this is true to some extent, it wiU. be seen later when speaking 
of the Bacteriology of the Urethra, that a small aseptic instrument may cause in- 
fection because the traumatism produced by the passage of a sound, increases the 
virulence of the urethral flora, which normally is in a semi-saphrophytic state of life. 

On the other hand, the general practitioner with less ability in the handling of 
sounds especially when the urethra is inflamed and edematous will cause false 
passages, increase the liability of stricture at the point of laceration and predispose 
the deep structures to infection and its consequences. It is our object to urge 
early surgical treatment in these cases and rational treatment of the later conse- 
quences. The expression, ' traumatic stricture,' must disappear from the medical 
vocabulary if the intervention in acute cases be immediate and rational." — Sur- 
gery, Gynecology, Obstetrics, Oct., 1906. Nefi and Schrayer, Murphy's Clinic, 
Chicago. 

554 



r 



SYMPTOMS OF RUPTURE OF THE URETHRA. 555' 

Rupture of the urethra, therefore, is always a serious injury, and in 
ordei that its dangers may be obviated, promptness of recognition and 
intervention is imperative. 

The symptoms of injury to the urethra are definite though varying 
in degree and are: retention of urine; hemorrhage from the urethra; 
and perineal tumor. 

These symptoms, together with the history of the case, readily make 
the diagnosis, but only by a careful study of each, recalling at the same 
time, the anatomy of the urethra, may one decide upon the location 
of the injury. 

(a) detention of urine accompanies in some degree all traumatic 
ruptures, though one should not make a diagnosis from this symptom 
alone for retention may follow a mere contusion — an interstitial 
rupture, without any solution of the continuity of the canal and without 
obstruction. It has its origin in "shock," perhaps, with temporary 
paralysis of the bladder musculature. In such a case, there is gradual 
development of a perineal tumor from the contusion but, on the other 
hand, the bladder slowly fills and rises out of the pelvis. 

In a few hours, the urine begins to dribble; a little later micturition 
becomes voluntary though painful and gradually the function is 
restored to the normal. In actual rupture, the retention is complete 
and continuous. 

(b) Hemorrhage jrom the urethra is indicative of rupture, but its 
amount in no wise points to the degree of urethral destruction. No 
inference may be drawn from it as to the severity of the lesion. In 
fact, the slighter the hemorrhage, the worse the outlook if the other 
symptoms are aggravated. For instance, if the mucous membrane 
alone is torn, the hemorrhage is immediate, perhaps voluminous, and 
yet the lesion is of minor importance. On the other hand, if the 
rupture is complete, the blood pours out into the lacerated tissues of 
the perineum and only a few drops may find their way through the 
occluded canal. Therefore, one must never conclude that because 
the hemorrhage from the meatus is slight, the injury is slight. 

(c) Perineal Tumor. — There is always swelling in some degree follow- 
ing contusions of the perineum whether the urethra is injured or not. 
The perineal and scrotal tissues are ecchymosed and the scrotum 



556 RUPTURE OF THE URETHRA. 

especially is likely to be engorged with exudates. If the urethra is 
ruptured the bladder empties itself into the bruised perineal tissues, 
the ecchymosis rapidly becomes an edema gradually thickening and 
expanding. At first perhaps an ovoid swelling in the middle of the per- 
ineum, it gradually spreads until the scrotum, the pelvis and finally 
the abdominal walls are infiltrated, thickened or edematous to a 
marked degree. But do not forget that the absence of a perineal 
tumor does not always mean that the injury is slight. If the rupture is 
situated behind the anterior layer of the triangular ligament and if 
this is not torn, the transudates cannot reach the perineum, for this 
tendinous band limits the forward movement of the urine and so, taking 
the direction of least resistance, it percolates through the cellular 
tissues of the pelvic cavity and passes up along the side of the bladder 
to the abdominal wall. Since, however, the anterior layer of the tri- 
angular ligament is nearly always torn to some extent, perineal swelling 
is nearly always present. Slight swelling will give no feeling of se- 
curity that the injury is slight. It is obviously essential that one must 
have clearly in mind the anatomy of the urethra. 

THE ANATOMY OF THE URETHRA. 

Stretched across the anterior segment of the pelvic outlet, between 
the rami of the pubes, is the triangular ligament, dense and fibrous 
and arranged in two layers, separated by a one-half inch space. In 
contact wdth the deep or pelvic surface of the triangular ligam^ent, is 
the apex of the prostate gland. In contact with the superficial or per- 
ineal surface, is the bulb of the urethra, the knobbed posterior ex- 
tremity of the corpus spongiosum. The urethra traverses the prostate, 
perforates and bridges the space between the two layers of the tri- 
angular ligament and then tunnels the bulb, runs the length of the 
corpus spongiosum, and emerges at the glans penis, the anterior 
knobbed extremity of the corpus spongiosum. The part of the ure- 
thra anterior to the triangular ligament, consists, then, of two portions, 
the penile and bulbous; the deep urethra of two, the prostatic and 
membranous w^hich later is the part which bridges the one-half inch 
space between the two layers of the triangular ligament. The clinical 
manifestations of rupture depend upon whether the bulbous or mem- 






TREATMENT OF CONTUSION OF THE URETHRA. 557 

branous portion is involved and in a minor degree upon whether the 
rupture is partial or complete. (See Fig. 448.) 

CONTUSION OF THE BULBOUS PORTION. 

Injury to the bulbous portion is by far the more frequent; it is the 
form which the practitioner will nearly always find. It remains for 
him to decide whether the injury is a contusion or rupture, for the prog- 
nosis and treatment are quite different in the two degrees of injury. 
If the case is one of contusion, it is likely the hemorrhage was abundant; 
the patient complains of pain and inability to pass water; there is no 
perineal tumor though the tissues may be much bruised. After a 
few hours he begins to pass water after painful effort. The urethral 
bleeding may persist but the bladder keeps well emptied. 

Treatment. — The treatment is very simple. Keep the patient 
-quiet, relieve the pain if necessary with small doses of morphia and 
give some urinary antiseptic such as urotropin. 

Do not pass a catheter. Why should you? The bladder empties 
itself; there is no perineal infiltration; and to do so would only in- 
crease the risk of infection. The normal micturition will return in a 
few days in the cases of mild contusion and perhaps in a week the 
patient w^ill be well. If, however, in such a case, after a few days 
micturition should become more painful and finally impossible, due 
to urethral swelling or spasm, catheterization is indicated. Try a 
large, soft, aseptic catheter first; try to carry it gently along the upper 
wall of the urethra. You may fail and be forced to fall back on a 
catheter of small size, but in no case must violence be used or the 
attempts prolonged. The catheter may be left in if the introduction 
was difl&cult, but it must be kept under constant surveillance and at 
the first appearance of a perineal tumor, indicative of infiltration, 
operation is imperative. If a catheter of small size has to be employed, 
it may not fill the urethra and there may be some dribbling of urine, 
which favors infection. In such a case the catheter remaining in the 
bladder may keep it empty by siphonage. 

Contusion, with the formation of a large hematoma in the perineum, 
might simulate rupture, but the presence of a distended bladder dem- 
onstrates that the perineal tumor is not infiltrated urine. In such 



558 RUPTURE OF THE URETHRA. 

a case again, an attempt should be made to pass a catheter if the 
urine does not begin to flow after three or four hours. If successful, 
the size of catheter may be increased from day to day. 

It must be borne in mind in making the first attempt, that too per- 
sistent effort may result in rupture of the already contused urethra, 
or insure infection. 

In case of failure, you may follow the recommendation of Lejars, 
and proceed to drain the bladder by suprapubic puncture and it may 
be, after a day or two when the swelling has subsided, a catheter can be 
passed and drainage secured in that manner as before, but hold your- 
self ready to operate at the first sign of infiltration. 

This line of treatment can only be recommended to those who are 
sure they can distinguish between hematoma following contusion, and 
infiltration following rupture. In case of doubt, always treat the case 
as one of rupture. 

RUPTURE OF THE BULBOUS PORTION. 

Urethral hemorrhage, rapidly increasing perineal tumor obviously 
due to infiltrating urine, and retention of urine following injury point 
at once to some destruction of the urethral wall. 

There is no use of wasting time attempting to pass a catheter; 
prepare at once for an external urethrotomy. Even if you succeed 
in passing a catheter, it will not prevent extravasation in the end, as 
Reginald Harrison and others have pointed out. Nor is there need to 
wait for additional symptoms. The indications for operation are un- 
mistakable. Delay merely exposes the patient to all the risks of 
infection. The end in view is to furnish a free outlet for the urine and 
if possible to repair the ruptured canal. 

Operation for External Urethrotomy. — ^Provide for the operation 
soft rubber catheters of various sizes; a grooved staff or steel sound; 
small, curved needles, silk No. o and three or four sizes of catgut. 

General anesthesia is indispensable. Place the patient in the lithot- 
omy position with the perineum exposed to a good light. The 
entire field must be disinfected with extreme care. 

As soon as the patient is anesthetized, an effort may be made to 
pass a catheter, and if successful, the operation will be greatly facili- 



OPERATION FOR RUPTURE OF URETHRA. 



559 



tated. Otherwise pass the guide as deeply as possible without using 
force and let it be held in position by an assistant who also supports the 
scrotum. 

The median incision extends from the base of the scrotum to within 
an inch of the anus. Divide the skin and fascia, when you may reach 
an area filled with clots and lacerated tissues, the site of the bulb and its 
muscular coverings (Fig. 425). You may not be able to recognize the 
bulb if the destruction has been great, but after wiping out the clots 




Fig. 425. — Incision exposing the bulb of the urethra. (Duval.) 



and debris, a cavity is exposed (Fig. 426). Expose the point of the 
guide and you have thus located the opening into the distal half of 
the urethra. Determine the nature of the urethral tear, whether 
partial or complete. ' The subsequent procedure will depend largely 
upon the type of injury present. 

(a) If you find rupture of the lower wall only, the remnant of 
the upper wall, a mere band perhaps, will be a great help in the next 
step, which is to locate the orifice of the urethra on the farther side of the 
tear. The search for this opening must be patient and minute. Let 



560 RUPTURE OF THE URETHRA. 

the point of a probe or grooved director follow the remnant of the 
upper wall backward and it may haply engage in the orifice and pass 
on into the bladder; if it does tiot, every bit of the mangled tissue must 
be examined. 

Another manoeuvre may be tried : if you have a soft rubber catheter 
in the urethra, pull it down into the wound and endeavor to engage 
its point in the hidden orifice. Once the orifice is found and the cath- 
eter carried into the bladder, try to suture the urethral wound over the 




Fig. 426. — The muscular and erectile-tissue of the bulb divided, 
exposing the urethra. (Duval.) 

catheter. Place lateral sutures of fine silk or catgut, beginning at 
the upper wall and suturing toward the lower where the separation 
is greatest. If possible, pass the suture through the outer coats only. 

(b) If the rupture is complete and the two ends are widely separated 
the difi&culties are aggravated. There is no relict of the upper wall 
left to assist in the slightest degree in locating the orifice of the prox- 
imal segment of the urethra. 

''With the point of the grooved director, every small orifice, every 
depression, every fringed tubercle must be examined in the hope that 
it represents the opening." 



OPERATION FOR RUPTURE OF URETHRA.- 



561 



If you find something which looks like mucosa and the lumen of 
the canal, introduce the point of your catheter and if it is in the right 
track, it will glide into the bladder. 

" A good light, patience, perseverance and an accurate knowledge of 
the anatomical relations of the injured parts, often lead to success in 
the most difficult cases." (Senn's Practical Surgery.) 




Fig. 427. — Soft catheter passed into the bladder after repair 
of the upper wall. (Duval.) 



Pressure on the bladder may sometimes help by forcing a drop or 
two of urine through and thus exposing the urethral opening. Some- 
times bleeding from the ruptured artery of the bulb will serve as a 
guide to the hidden opening. 

The incision may be extended backward with a view to exposing the 
canal but this is often unsatisfactory and care must be taken not to 
wound the anal sphincter. 

If, by any of these means, the orifice is finally located and the cath- 
36 



562 



RUPTURE OF THE URETHRA. 



eter passed into the bladder, it remains to adjust and suture the divided 
ends. The ideal way consists in making an end-to-end anastomosis, 
passing the sutures through the outer coats only. Occasionally you 
will be satisfied if, by passing sutures through all the coats, you 
can approximate, in some degree, the two ends, favoring by that much, 
the utimate restoration of the canal and minimizing the stricture 
formation (Fig. 427). 

" In twenty-nine reported cases of rupture of the urethra, treated by 




Fig. 428. — Repair of the muscular layers. (Duval.) 



immediate suture, all are announced as successful. These results are 
astonishing and commend repetition." (Bryant's Operative Surgery.) 

After suture of the urethral tear, the perineal wound may be short- 
ened a little by one or two sutures, but ample space must be left for 
drainage. A wound unnecessarily large is much less dangerous than 
one too small (Fig. 428). 

Pack the wound with iodoform gauze. The catheter should be 
left in the bladder for three to four days, when it is removed and a 
steel sound passed thereafter every two or three days until repair is 
complete. 



SUPRA PUBIC CYSTOTOMY. 563 

(c) What are you to do in case patient search fails to locate the 
bladder end of the torn canal and you are unable, therefore, to pass the 
catheter into the bladder and to suture ? Two procedures are recom- 
mended: 

(i) Pack the wound with iodoform gauze and empty the bladder 
as necessary by suprapubic puncture. Perhaps at a later examina- 
tion the opening may be found, or, as will nearly always happen, the 
bladder is sufficiently drained after a day or two, through the perineal 
wound. 

(2) Do a supra-pubic cystotomy and "retrograde catheterization." 
Where the general condition of the patient and other circumstances 
permit, this procedure is the better, since it assures drainage and 
facilitates primary repair by definitely locating the bladder end of 
the torn urethra in the perineal wound. It is necessarily a delicate 
operation and should not be undertaken by the wholly inexperienced. 

To perform supra-pubic cystotomy, and retrograde catheterization 
begin by carefully disinfecting the abdominal wall. Make an incision 
two and one-half inches long in the middle line, beginning at the 
pubes and cutting through the skin and subcutaneous tissues and 
the fascias. Retract the lips of the wound widely. You may not 
be able to distinguish the peritoneal covering of the bladder for it may 
be above the upper level of the wound. In any event, it must be pushed 
up out of the way. Next locate the bladder, which is easily felt if it 
is distended; but if it is not, follow the posterior surface of the pubes. 

Transfix the anterior wall by a suture on each side of the proposed 
line of incision, and lift the bladder upward to the abdominal wound 
and open it by a free incision. A small incision is a nuisance while 
a large incision renders the subsequent steps easier and is easily sutured 
at the end of the operation. 

With the bladder opened, the next step is to pass the catheter. 
If possible locate the urethral orifice in the bladder and pass the 
catheter by sight, but you will usually have to depend upon touch for 
this procedure. 

Introduce the left index and middle fingers into the bladder and 
touch the base. Now draw the fingers forward in the middle line 
and the neck of the bladder will be recognized by its relation to the 



564 RUPTURE OF THE URETHRA. 

prostate and the urethral opening feels like a pimple on the base of 
the gland. The catheter is now slipped along the finger resting on the 
orifice. Once engaged, it is pushed on through the urethra until its 
point emerges in the perineal wound. Couple it onto the soft catheter 
in the anterior part of the urethra and retract it through the abdominal 
wound, and by this means the catheter in front is drawn into place 
and should be left in the bladder after the urethral and perineal 
wounds are sutured, as before described. 

We must now provide for the drainage of the bladder through 
the supra-pubic wound. Empty a medium size catheter and let 
it reach almost to the bottom of the bladder and anchor it in place 
with a safety pin. Suture the bladder wound tightly about the tube. 
Repair the abdominal wall, leaving enough room for light gauze 
packing about the tube. 

"Many elaborate methods of suprapubic drainage are described, 
but this tube connected to a long rubber tube by means of a glass 
coupler and terminating beneath the bed in a bottle filled one-quarter 
full of bichloride solution, will meet all the requirements of the case." 
(Taylor, G. U. and Venereal Disease.) 

The tube may be replaced by a smaller one after two or three days. 
As soon as possible, the wound is allowed to fill up by granulation and 
the drain is entirely removed. 

RUPTURE OF THE MEMBRANOUS URETHRA. 

This accident is rare except in connection with fractures of the pelvis. 
Under any circumstances, it is even more dangerous than rupture in 
front of the triangular ligament, for the extravasated urine may easily 
spread up into the pelvic cavity and induce cellulitis and general in- 
fection. Examination per rectum will often reveal the edema, no 
signs of which appear in the perineum. 

Nothing but free incision and drainage through the perineum is 
of any use. 

Finally the pendulous portion of the urethra may be ruptured, some- 
times in coitus and the hemorrhage may be quite alarming to the pa- 
tient; there may also be retention of urine. Usually catheterization 
will be sufficient. 



CHAPTER XIX. 

ACUTE RETENTION, CATHETERIZATION, SUPRA-PUBIC 
PUNCTURE, CYSTOTOMY, URINARY INFILTRATION. 

Every acute retention of urine demands immediate relief. It 
must be relieved not only on account of pain and discomfort, but more 
especially to avoid damage to the bladder or urethra and the evil effects 
of sepsis. This rule applies equally to the cases due to temporary 
insufficiency of the bladder musculature and to those due to urethral 
obstructions. 

Urethral obstruction may assume various forms. In general prac- 
tice, it will usually originate in one of three ways ; spasm of the urethra, 
enlargement of the prostate gland, or stricture. Very .many more 
times than we suspect in those cases regarded as simple retention from 
spasm, the real and predisposing cause is organic. In every case 
before instituting measures for relief, it is wise to make minute inquiry 
into the patient's history with respect to this function. At least one 
should be suspicious of the presence of .'•tricture and on his guard. 

It is true that in a particular case certain circumstances tend to 
make one or the other of the causes of retention the more probable. 
Thus if the patient is in a febrile attack or has suffered some slight 
trauma of the urethra or has undergone an operation on a region 
adjoining the urinary tract, one thinks of retention from urethral 
spasm. If the patient is known to have a sexual history — has been a 
votary at the shrine of Bacchus and Venus, the logical inference is 
organic stricture. If the afflicted one is elderly, one thinks of enlarged 
prostate, though mere age does not rule out other causes of obstruc- 
tion. One may be past the hey-day of life and yet strictured, paying 
late the price of pleasures long since fled. 

But after all, whether the predisposing cause is temporary or 
permanent, the actual exciting cause is usually congestion. This is 
a practical point constantly to be borne in mind, for it is congestion 



566 



CATHETERIZATION. 



which makes urethral instrumentation potent to produce trouble, 
and which makes strict asepsis an absolute necessity. 

CATHETERIZATION. 

The first measure of relief to be tried in actual retention, if opium 
and a prolonged warm bath are not practical, is catheterization. To 
meet the possible indications every practitioner should be armed. 
A certain equipment is indispensable. 

A cylindrical metal case capped at one end is most convenient in 
which to keep and carry these instruments. The most essential 
are soft rubber catheters of various sizes, flexible bougies with olivary 




Fig. 429. — Conical. 
Fig. 430. — Olivary. 

Fig. 431, — Cylindrical. 
(Stewart.) 



Fig. 432. — Elbowed flexible catheter. 




Fig. 433. — Mercier double elbowed flexible catheter. 



and conical tips, gum catheters with single and double elbows or 
armed with stylets, fiHform bougies (Figs. 429, 430, 431, 432, 433).- 

Sterilization of these instruments may be a problem, except as to 
the rubber catheters, which may without injury be disinfected by 
boiling. The other instruments are best sterilized by formaldehyde 
vapor and should be prepared before leaving the office and carried 
wrapped in sterile cloths. 

Without the special sterilizer, one must boil these instruments, 
risking eventual injury. They may be fairly well cleaned by rubbing 
with an antiseptic ointment or by immersion in a 1-20 carbolic or 



CATHETERIZATION. 567 

i-iooo bichloride solution. Previous to its introduction, anoint 
the catheter with sterile vaseline or similar lubricant. 

Position oj Patient. — The patient should lie upon a table high enough 
that the operator does not need to stoop. The pelvis should be 
elevated and the thighs flexed and abducted. Begin by thoroughly 
cleansing the field; cleanse the penis, the foreskin on both sides, the 
glans and the meatus, wiping each part with a separate compress. 
If possible, irrigate the urethra with boric acid or normal salt solution. 

Whatever condition may be suspected in an unexplored urethra, 
make the first attempt at relief with a large catheter, seventeen or 
eighteen French, which, as is well known, excites less resistance than 
one of smaller size. Standing at the patient 's left side, hold the penis 
between the finger and thumb of the left hand, elongating it, while 
managing the catheter with the right. Usually it is best to hold the 
instrument parallel with the groin as its beak enters the meatus, 
gradually bringing the handle to the middle line of the abdomen as 
the instrument penetrates. As the catheter progresses it may be helped 
along by giving it a slightly boring motion. Proceeding thus gently 
but steadily, always avoiding force, the bladder may be reached. If 
not, a smaller catheter is to be tried and so on until one is found that 
will enter. If all these efforts fail, and it becomes evident that a prac- 
tically impermeable stricture is present, resort must be had to filiform 
bougies, which may be bent into various shapes, bayonet shape, or 
corkscrew form, and kept so by a thick collodion coating. 

A filiform bougie is passed until it engages and then various back 
and forth, side to side, movements are imparted with the hope of 
finding a passageway through the scar tissue. The point may engage 
in lacunae or in false passages and often it is useful to leave the bougie 
in situ. A half dozen may be left in the urethra to occupy the false 
passages, until haply one finally passes into the urethral canal. Once 
a bougie is introduced into the bladder, it should be fastened and left 
until the second day, when often it may be replaced by a soft catheter 
or a larger bougie. In the meantime, the urine trickles past the 
stricture drop by drop, until, in a short time, the distention is relieved. 

If the retention is known from the first to be due to stricture, the 
procedure may vary somewhat. Valentine and Townsend have 



568 



CATHETERIZATION . 



defined the technique of emergency dilatation of urethral stricture, 
in such a satisfactory manner (American Journal of Surgery, May, 
1907) that it is transposed for present use practically in its entirety. 

The hyperesthesia of the urethra, often so great an obstacle in 
catheterization, is greatly relieved by filling the urethra with a thirty- 




PiG. 434. — Lubricating the urethra. (Am. Jour. Surgery.) 



three per cent, solution of malaleuca sempervirens in sterile oil and 
holding it for three to five minutes. Local or general anesthesia is 
undesirable. 

No lubricant is used for filiforms but the urethra is to be filled 
with ten per cent, suspension of iodoform in glycerine, injecting with a 
sterile glass syringe of one ounce capacity. The penis is held in the 
left hand, the index finger and thumb pressing the meatus open. The 



MODE OF INSERTING A FILIFORM BOUGEE. 



569 



tip of the syringe is inserted and the contents slowly injected until 
it can be felt that the urethra is full (Fig. 434). When the injection 
is complete the finger and thumb compress the meatus to prevent 
the escape of any of the fluid to make the fingers or penis slippery. 

The filiform is to be inserted. A straight bougie, 5 French, is in- 
serted as far as it will go without force (Fig. 435). A smaller one is 
then passed alongside the first and the procedure continued with 




Fig. 435. — Inserting a filiform, (American Journal Surgery.) 



smaller straight bougies until a No. i has been inserted as far as 
possible. This is then left in place and from three to six more intro- 
duced, each one being left at the point of arrest. 

When as many filiforms as will pass the meatus without stretching 
it are thus inserted, the one first introduced may be urged slightly 
forward. If its point is free but cannot progress, it may be withdrawn 
and an angular filiform inserted in its place. It should be gently 
rotated to the right and left as obstruction is met with. If it makes 



570 



CATHETERIZATION. 



no progress, it may be left in place and another of the straight filiforms 
withdrawn to be' replaced by a bayonet filiform. The bayonet 
filiform is to be pressed forward and then withdrawn slightly and 
again advanced in a different direction, hoping to find the lumen. 
If this fails, the corkscrew filiform is to be tried, removing s6me of 
the straight filiforms if necessary to have more room. 

When the corkscrew's tip reaches the face of the stricture, it is to 




Fig. 436. — KoUmann filiform guides. (American Journal Surgery.) 

be rotated, trying first the right spiral and then the left. If the second 
one fails, leave it in place and try each of the straight ones again, push- 
ing it gently forward and if it fails to enter, withdrawing it. After all 
the straight ones are tested and removed, try the corkscrew that 
remains in the urethra and then the one tried first. 

If all these manoeuvres have failed, an attempt may be made with 
the Kollmann guide (Fig. 436). A straight or curved guide is to be 




Fig. 437. — Valentine-Townsend filiform carrier. (American Journal Surgery.) 



used, depending upon the location of the stricture. It is passed up 
to and pressed firmly against the face of the stricture while a straight 
filiform is introduced and lightly pushed against the stricture, changing 
the position of the guide from time to time. If this attempt with the 
Kollmann guide fails, a metal sound as large as will pass to the stric- 
ture by its own weight is introduced and held against the stricture 
for five minutes or more and quickly withdrawn and the urethra 



MODE OF ANCHORING A FILIFORM BOUGIE. 



571 



refilled with the iodoform-glycerine solution and all the manoeuvres 
with the filiforms repeated, often with the result that the first inserted 
will traverse the stricture and enter the bladder smoothly. 

The urethroscope is sometimes useful in locating the orifice, but 
even then the filiform may be difficult to enter, manifesting the "per- 
versity of things inanimate;" although the shortest urethroscope tube 
be used, the filiform will cling to its sides or will sway to and fro, 
touching every point of the exposed 
region except the orifice. Under the 
circumstances, the Valentine-Townsend 
filiform carrier (Fig. 437) is to be recom- 
mended and its use is thus described: 

After the urethroscopic tube is in- 
serted, the urethral mucosa dried, and 
the light in place, the carrier, armed with 
a filiform, is inserted. The lower most 
ling containing the filiform's tip is 
pressed against the face of the stricture 
at the point where its lumen is visible. 
Once fixed by slight pressure, the filiform 
is very slowly projected into the exposed 
lumen. If it fails to traverse the stric- 
ture, an angular and then a corkscrew- 
filiform are tried as before described. 

Whenever a fill jot m reaches the bladder, 
the fact is announced by the ease with 
which the instrument can be moved to 
and fro and by the increased desire to 
urinate when the filiform touches the bladder walls 
urine trickle by the filiform. 

The -filijorm must he fastened in place: No effort must be made 
at this time to pass a larger instrument. Valentine and Townsend 
recommend the following method of holding the filiform in place: 

Two pieces of sterile cord six inches long are used, one tied about 
the bougie in front of the meatus so that the knot corresponds to the 
dorsum of the penis, and the other tied so that the knot corresponds 




Fig. 438. — Cord attached to in- 
strument in urethra. (American 
Journal Surgery.) 



A few drops of 



572 CATHETERIZATION. 

to the insertion of the frenum , (Fig. 438). "Take the cords pro- 
jecting from one side of the glans and pass them through one of the 
four holes of a common pearl shirt button, draw the button upon the 
two joined cords until it rests exactly at the post coronary sulcus. 




Fig. 439. — Attaching button to cord. (American Journal of Surgery.) 

Tie a knot in each cord at that point to fasten the button in place" 
(Fig. 439). Proceed in the same manner on the opposite side. 

A cord passing over the penis connects the two buttons; another 
passing under the penis is threaded on to the two buttons and tied, 
care being taken not to disturb the position of the two buttons (Fig. 440). 
Finally a cord twelve inches long is fastened into the remaining hole 




Fig. 440. — Uniting cords attached to button , lateral holes. (American Journal of Surgery.) 

of each button, and carried backward to be attached to the pubic 
hairs after Guyon's method (Fig. 441). 

" The penis is then to be dressed, covering it with an aseptic garment. 

"Three layers of sterile gauze ten inches square are folded to form 
a triangle. This is passed under the penis with the base toward the 
scrotal angle. The apex is tied to the instrument ^t its projection 



RETENTION DUE TO ENLARGED PROSTATE. 



573 



from the meatus. The two angles at the base are carried in front 
of the penis, one above the other, and their points are attached to the 
pubic hairs by the extremities of the cords left after tying in the 
instrument" (Fig. 442). 

A pad of cotton should cover the genitals, and the whole be covered 
by a towel, to be changed as often as soiled. 





Fig. 441. — Cords attached to pubic 
hairs. (American Jour, of Surgery.) 



Fig. 442. — Penis dressed. (American 
Journal of Surgery.) 



"While it is better that the patient with a filiform fixed in his 
bladder remain in bed, there are circumstances in which it is impera- 
tive that he be allowed to go about and attend to his occupation. 
Protected against the dangers of retention as above, this is permis- 
sible unless he be engaged at hard labor." 

In the case oj retention due to enlarged prostate, the mode of procedure 
is quite different if the primary effort at passing a soft catheter fails. 

The prostatic catheter with l^ng curve may be tried, passing 



574 PUNCTURE OF THE BLADDER. 

it as deeply as possible before depressing the handle between 
the thighs, pulling the penis upward, elongating it to facilitate the 
movement of the sound. Once the point is in the perineal region, 
the handle is to be depressed rapidly, at the same time pushing the 
sound on, hoping in this manner to carry it over the prostatic pro- 
jection. No force must be employed. Often the Mercier elbowed 
or double elbowed catheter will surmount the diflSculty (see Figs. 432 
and 433). 

Sometimes a large gum elastic catheter armed with a stylet may be 
useful. The catheter is introduced to the obstruction, the stylet 
slightly withdrawn, which serves to tilt the end of the catheter and 
permits it to be pushed on into the bladder. 

In these cases of chronic enlargement of the prostate frequent 
catheterization may be required. As Stewart (Surgery, page 653) 
says, if it becomes difficult, if there is marked irritability of the bladder, 
if the residual urine steadily increases in quantity, or if there is stone 
or persistent cystitis, catheterization must be abandoned and oper- 
ation advised. 

PUNCTURE OF THE BLADDER. 

When catheterization has failed and relief is imperative, supra- 
pubic puncture is the next resort. It is in no wise dangerous if aseptic, 
except possibly in those long strictured or long troubled with enlarged 
prostate, when the peritoneal covering of the bladder may approach 
the pubes. 

Begin with a careful disinfection. Shave and scrub the abdomen 
and pubes. Select for puncture, the point immediately above the 
pubes in the middle line exactly. The instrument, which may be an 
aspirator or simply a trocar, is to be entered at the point indicated, 
without fear of going too deep, and pushed backward and slightly 
downward until resistance ceases. Withdraw the stylet and the urine 
follows in a steady stream. A rubber tube may be attached to the 
trocar. The bladder should not be emptied rapidly, but slowly, 
interrupting the flow from time to time. When the bladder is emptied, 
the trocar is to be withdrawn with a rapid movement, and the opening 
covered with a sterile compress, or if quite small, with collodion. 



CYST ATOMY. 575 

Aseptic puncture may be practised once or twice a day for a number 
of days without serious consequences, and at the end of this time 
the congestion of the urethra may be relieved and the urinary function 
restored. If, however, at this time the urethral obstruction cannot 
be overcome, then one must proceed to establish permanent drainage. 

Permanent drainage is indicated from the first if distance precludes 
two or three daily visits, for there is no use to relieve the patient by 
puncture and then leave him to the danger and pain of a new retention, 
certain to occur. 

Again, if the urethra has been lacerated by rough attempts at 
catheterization, and if to the symptoms of retention are added those 
of sepsis and the signs of beginning infiltration, it is imperative to 
establish permanent drainage of the bladder. 

Under these circumstances the puncture may be performed with a 
large trocar, and after the bladder is emptied a catheter can be passed 
through the canula into the bladder as far as possible and the canula 
gently withdrawn. 

The catheter must be fixed in position, and this can readily be done 
by threads attached to the skin with collodion. To the catheter a 
long rubber tube should be attached, ending below in a vessel con- 
taining an antiseptic solution. By this means a siphonage is estab- 
lished and the bladder kept constantly emptied and prevesical in- 
filtration avoided. 

CYSTOTOMY. 

Permanent drainage through the supra-pubic puncture is often 
alone available, though by no means ideal. Whenever possible, the 
bladder is to be opened formally and the drainage established by that 
means, nor is the operation beyond the skill of the general practitioner. 

No special equipment is necessary; scalpel, scissors, artery forceps, 
dissecting forceps, small curved needles. Local anesthesia may be 
employed in case of necessity, though, of course, general anesthesia 
is desirable. The region is to be carefully prepared. 

Operation. — Begin with an incision three inches long commencing 
at the pubes and extending upward in the middle line (Fig. 443). 
Divide the skin and fat down to the aponeurosis. Divide the aponeu- 



576 



CYSTOTOMY. 



rosis and expose the prevesical fat (Fig. 444). Draw this fatty tissue 
upward, and with it the vesical peritoneum, exposing the bladder. 
The bladder appears dark and globular, marked by large veins. In 
fat subjects, it may seem deeply situated in spite of its distention, 
but one need not fear to get into something else (Fig. 445). 




Fig. 443. — Cystotomy. Primary incision exposing linea alba. 



It is helpful in controlling the bladder and later on in suturing, 
next to pass a suture on either side of the proposed line of incision. 
The sutures should pass through only the superficial tissues and be 
parallel to the bladder incision. Next proceed to open the bladder 
in the middle line making the puncture at the level of the pubes with 
the cutting edge of the bistoury turned upward, prolonging the in- 



CYSTOTOMY. 



577 



cision from a half inch to an inch. If the sutures have not been 
passed, catch up the edges of the vesical wound with forceps while 
the urine flows out. 

The bleeding, often considerable at first, is not a matter for concern 
and ceases^spontaneously as the emptied bladder contracts. 





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Fig, 444. — Cystotomy. Recti separated, prevesical fat exposed. 



When the bladder is emptied, douche it thoroughly with warm 
sterile water and explore its cavity for possible calculi. 

It remains to suture the edges of the bladder wound to those of 
the skin wound (Fig. 446). If the traction sutures mentioned 
were passed, they may now be used to draw the bladder up into close 
contact with the abdominal wall, passing them through the entire 
thickness, and tying them on the outside. 
37 



578 



CYSTOTOMY. 



The mucous membrane is now brought in contact with the skin 
and sutured with catgut (Fig. 447). If the condition of the vesical 
walls does not permit the careful coaptation described, then four or 
five sutures may be employed, passing through all the layers of the 
bladder and abdominal walls, bringing them into contact. In this 




Fig. 445. — Partial incision of the deep layer of the sheath of the 
recti, exposing the prevesical fat. 



case a catheter must be introduced and siphonage instituted. In 
the first case where the skin and mucosa are exactly coapted, it is 
not necessary to leave a catheter in the bladder. The skin wound is, 
of course, sutured above and gauze should be packed around the 
catheter. The after history will depend upon the condition present, 
but the ultimate aim will be to restore the urethral functions. 



SYMPTOMS OF INFILTRATION. 

INFILTRATION OF URINE. 



579 



Sometimes it happens that following a retention, partial or com- 
plete, the urethra gives way and the urine percolates through the 
adjoining tissues. Under these circumstances, the urine is nearly 
always septic, the patient debilitated, and the conditions are thus ripe 
for a rapid fatality.^ 




Fig. 446. — Cystotomy. Bladder fixed to the abdominal wall, sutures passing 
through the recti; bladder opened. 

Shortly after the rupture of the urethral wall, the perineal tissues 
become edematous, and the scrotum and penis markedly swollen. 
The infiltration soon involves the pubic and hypogastric regions. 

The symptoms are those of sepsis; rigors, fever, pulse rapid and 
weak, tongue dry, anxious facies, profound depression generally, 
the symptoms depending in degree upon the duration of the accident, 



S8< 



INFILTRATION OF URINE. 



4 


- 




\! 


/' 


1 


I 



Fig, 447. — Cystotomy. Sutures connecting the edges of the bladder wound 
and the skin. Repair of the abdominal wall. 



TREATMENT OF INFILTRATION. 58 1 

the rapidity of the urine's spread and its septicity. Diffuse phlegmon 
and gangrene may rapidly ensue. 

The rupture usually occurs in front of the triangular ligament — 
the deep perineal fascia — and so the urine moves forward toward 
the scrotum and pubes, which is the direction of least resistance 
(Fig. 448). 




Fig. 448. — Rupture of the urethra in front of the deep perineal fascia and at point of 
entrance to the bulb; showing the direction which the infiltrating urine may take into penis 
and scrotum, perineum and supra pubic region. (Veau after Hartmann.) 

The treatment has two ends in view, to relieve the burdened tissues 
and to open up a passage to the point of rupture. To relieve the 
engorged tissues, a series of parallel incisions are to be made, extending 
beyond the limits of apparent infiltration, for the deeper tissues are 
always more widely involved than the superficial. The incisions 
should be deep enough to reach the deep fascia. The bleeding is not 
likely to be serious, but any bleeding points may be caught up and if 
the oozing still persists, the incisions may be packed with iodoform 
gauze. 



582 INFILTRATION OF URINE. 

To expose the urethra^ put the patient in the lithotomy position 
and make an incision in the middle line, beginning at the base of the 
scrotum and terminating in front of the rectum (Fig. 449). There is 
no guide but the middle line, for the tissues, thickened and infiltrated, 
are unrecognizable. There is nothing to do but continue to cut, 
keeping in the middle line, until rewarded by a spurt of urine. 

All the incisions are to be thoroughly irrigated with hot normal 
salt solution, the tissues gently squeezed and the dead tissues removed. 
A compress saturated with peroxide is next applied, this covered with 
absorbent cotton and the whole retained by a T bandage. 




Fig. 449. — Peiineal incision for infiltration of urine. (Veau.) 

Ordinarily drainage is unnecessary, for the open wounds give free 
escape to the fluids. Often one is surprised at the completeness of 
the repair. 

At first the urine flows out through the breach in the perineum, 
but after a little while a catheter may be passed and fastened in the 
bladder and the perineal wound allowed to heal. 

Lejars prefers the thermo -cautery to the bistoury, both because the 
hemorrhage is less and because it exercises a salutary action upon the 
tissues about to become gangrenous, but Veau believes the knife to 
be better, because it does not seal the mouths of interstitial drains. 

If in the course of intervention, an abscess cavity extending up 



DILA.INAGE FOR INFILTRATION. 



583 



toward the pubes is found, a drainage tube must be passed as high as 
possible and fastened in position (Fig. 450). 

Sometimes it happens that the urethral rupture occurs behind the 
perineal fascia, and again taking the direction of least resistance, the 
urine may pass up along the side of the bladder to the deep layers of 
the abdominal wall; or it may pass downward and backward into the 




Fig. 450. — Infiltration of urine; placing drain. (Veau.) 



ischio-rectal fossae. This condition is all the more dangerous for 
the reason that the external manifestations are often delayed and in 
consequence the true condition is not suspected until too late. 

But whenever a zone of infiltration is found, wherever it may be, 
incise it and reach the urethra if possible. In the intra-pelvic in- 
filtrations it may be necessary to open and drain through the bladder. 



CHAPTER XX. 
SUTURE AND LIGATION OF ARTERIES. 

In emergency surgery the suture of a divided vessel is occasionally 
applicable, but the doctor will usually prefer ligation, which will nearly 
always suffice. 

To suture a vessel, the blood current must be under temporary con- 
trol by means of a clamp protected with rubber, that the tunica interna 
may not be injured. 

The vessel wall is seized with a fine forceps. The silk sutures are 
placed one-sixteenth of an inch apart in a longitudinal wound and only 
the outer coats are pierced. 

If an end-to-end anastomosis is required, three sutures are recom- 
mended by Murphy and the proximal end is invaginated in the distal, 
the sutures being passed first through the proximal and finally through 
the distal end from within outward and tied. 

The indications for arterial suture are as follows: 

1. Where ligation might bring about serious nutritional change. 

2. In all wounds of large vessels. 

3. Operative wounds where a part of the vessel must be sacrificed. 

LIGATION OF ARTERIES. 

It is a rule almost without exception that a divided artery must be 
exposed and both ends tied. 

Occasionally in the case of secondary hemorrhage, it will be im- 
possible to secure the artery at the site of the hemorrhage and ligation 
at some point in the course of the artery above the lesion will then be 
imperative. So that though only rarely to be used in emergency sur- 
gery, yet the technique of special ligations should be kept in mind. 

General rules for all ligations may be formulated: 

I. Put the patient in some position best to expose the artery and its 
landmarks. 

584 



GENERAL RULES EOR LIGATION. 585 

2. Outline the course of the vessel, using aniline if necessary. 

3. Tie the vessel but avoid tying near the origin of a large branch, 
if possible. 

4. Let the middle of the skin incision correspond to the point of 
ligation and let its length depend upon the depth of the vessel. 

5. Let the first incision include the skin and superficial fascia; the 
incision in each succeeding layer should be the same length as the first. 

6. Each structure must be identified as exposed. 




Fig. 451. — Ligation of an artery. A, opening the sheath; B, passing the 
hgature; C, tying the ligature. (MoulHn.) 



7. The sheath of the vessel is to be recognizejd by its position, pul- 
sation and feel to the examining finger. 

8. The sheath is pinched up in the form of a cone, the base of 
which is incised with edge of the scalpel turned away from the vessel. 

9. Through this small opening the vessel is gently detached and 
the aneurism needle passed, beginning usually on the side in relation 
with the vein and keeping it in close contact with the artery (Fig. 451). 

10. After the needle is threaded and withdrawn, be assured that 
other structures will be included in the ligature. 



586 



SUTURE AND LIGATION OF ARTERIES. 



11. Draw the knot tightly enough to occlude the lumen of the vessel 
but not tightly enough to crush the inner coat. 

12. The subsequent treatment is that of an ordinary wound. • 

THE COMMON CAROTID (Fig. 452). 

The line oj the artery corresponds to the anterior border of the sterno- 
mastoid. 

The incision should be three inches long in this line, the middle 
of the incision corresponding to the cricoid cartilage. Divide the skin, 




MustcioL Muscle 



Fig. 452. — Ligation of the common carotid and facial arteries. (Moullin.) 

fascia, platysma; catch the bleeding veins, and divide the deep fascia 
along the sterno-mastoid, exposing the sheath upon which lies the de- 
cendens hypoglossi and the omo hyoid. Just above the omo hyoid, 
open the sheath from the inner side so as to avoid the internal jugular. 
Pass the needle from outside, also to avoid the internal jugular. 



LIGATION or THE SUBCLAVIAN. 587 

EXTERNAL CAROTID. 

Line. — Continuation of the common carotid. 

Incision. — ^From the angle of the jaw to the thyroid cartilage, divid- 
ing the skin, fascia, and platysma. Ligate divided veins. 

Divide the deep fascia, exposing the sterno-mastoid, which is to be 
retracted. Locate the posterior belly of the digastric, the hypoglossal 
nerve, and the tip of the cornu of the hyoid. 

Expose the artery opposite the cornu; pass the ligature between the 
superior thyroid and the lingual arteries, avoiding the decendens hypo- 
glossi and the superior laryngeal nerve behind. The operation pre- 
supposes patience and a thorough knowledge of the anatomy. 
Through this same incision the superior thyroid, the lingual, the 
facial, the occipital and the ascending pharyngeal arteries may be tied 
at their origin. 

LINGUAL (Beneath the Hyoglossus). - 

Position. — ^Place the patient on his back, turn the head to the oppo- 
site side and raise the chin (Fig. 453). 

Incision. — Curved, its center just over the greater cornu of the hyoid, 
extending from the symphysis of the chin to the angle of the jaw. 
Divide the skin, superficial fascia, platysma and deep fascia. Ligate 
the numerous veins which may be divided. Locate the lower border 
of the submaxillary gland and divide its fascia, thus exposing it, and 
lift it upward out of the way. 

Develop the mylo-hyoid; also the two bellies of the digastric and 
draw them down firmly. In the bottom of the wound is the hyoglos- 
sus muscle. Identify the hypoglossal nerve with the lingual vein, which 
cross the hyoglossus. Incise the hyoglossus below, and parallel with, 
the hypoglossal nerve. Incising carefully, the artery bulges into the 
wound. Ligate the artery on the proximal side of the dorsalis linguas. 

SUBCLAVIAN (Third Portion). 

Position. — ^Place the patient on his back with shoulders raised, head 
turned to opposite side and angle of shoulder depressed (Fig. 453). 
Incision. — From the posterior border of the sterno-mastoid, over the 



588 



SUTURE AND LIGATION OF ARTERIES. 



clavicle, to the anterior border of the trapezius, drawing the skin down 
first to prevent wounding the external jugular. Relax the skin. The 
incision now lies one-half inch above the clavicle. If more room is 
needed, partially divide the trapezius and sterno-mastoid. Divide 
the deep fascia and ligate veins. 

If the trans versalis colli or the suprascapular arteries present, draw 
them to one side. 




Fig. 453. — Ligation of the subclavian and lingual arteries. (Moullin.) 



Now identify the scalenus anticus muscle — a very important step 
as it is the guide to the artery. Follow the external border of the muscle 
down to the first rib and there the pulsations of the artery will be felt. 

Identify the lowest cord of the brachial plexus, which, as well as the 
pleura and the subclavian vein, must be avoided in passing the ligature. 



¥ 



LIGATION OF THE BRACHIAL. 589 

THE AXILLARY (Third Portion). 

Position. — Patient supine, shoulders raised, arm at a right angle; 
operator between arm and body (Fig. 454)- 

Incision. — Along the line of junction of the middle and anterior 
third of the floor of the space. 

Divide the skin and fascia and expose the inner border of the coraco- 
brachialis. Draw the coraco-brachialis, the median and musculo-cuta- 
neous nerves outward, the ulnar and internal cutaneous nerves in- 
ward. Avoid the basilic and axillary veins. 

■Ziol/s 7;i//sc7c 




Fig. 4S4. — Ligation of the axillary artery. (MouUin.) 

BRACHIAL (In the Middle of Arm). 
(See operation for exposure of median nerve.) 

BRACHIAL (Bend of Elbow). 

Position. — Limb extended and abducted, operator outside of arm 
(Fig. 455). 

Incision. — Follow the internal border of the bicipital tendon, the 
center corresponding to the bend of the elbow. Divide the skin and 
superficial fascia. Isolate the median basilic vein and the internal 
cutaneous nerve, retracting them inward. Next divide the deep and 
the bicipital fascia and beneath this latter lies the artery with its venie 
comites, the median nerve to the inner side. 

Do not neglect to repair the bicipital fascia. 



590 



SUTURE AND LIGATION OF ARTERIES. 



RADIAL (In the Upper Third of Forearm). 

Position. — Hand supine, surgeon to outside cutting downward (on 
the right) (Fig. 456). 

Incision. — illong the inner border of the supinator longus for three 
inches, dividing the skin and superficial fascia. Divide the deep fas- 

Tcndinous Jfioneurcais 
_ divided 



/-4- 




Fig. 455- — Ligation of the brachial at head of the elbow; the median basilic 
vein and internal cutaneous nerve drawn inward. (Moullin.) 



Suliinator lorn/US' 




Fig. 456. — Ligation of the radial artery. In the floor of the wound is the pronator 
radii teres. The nerve lies some distance to the radial side. (Movdlin.) 

cia and separate the supinator longus and pronator radii teres. The 
artery lies under the border of the supinator longus with the nerve to 
the outer side. 

RADIAL (At Wrist). 

Position. — The position is the same as before. 

Incision. — The incision is along the supinator tendon. Avoid the 
radial vein and the superficialis volae artery. Divide the deep fascia 



LIGATION OF THE FEMORAL. 



591 



and separate the tendons of the supinator longus and flexor carpii 
radialis and between them lies the artery and its venae comites. 

ULNAR (At Wrist). 
(See exposure of ulnar nerve, page 266.) 



^^^^er??ta^cc Card 










Fig. 457. — Ligation of external iliac and femoral arteries. (Moullin.) 

SUPERFICIAL FEMORAL (At Apex of Scarpa's Triangle). 
Position. — Thigh slightly flexed, rotated externally, abducted; 
surgeon to outer side (Fig. 457). 

Incision. — Three inches long, with center over apex of triangle. 



592 



SUTURE AND LIGATION OF ARTERIES. 



Divide the skin and superficial fascia. Avoid the long saphenous vein. 
Divide the deep fascia and draw the sartorius outward; the adductor 
longus, inward. Avoid the internal cutaneous and the long saphe- 
nous nerves. The vein lies to the inner side and a little behind the 
artery. 

FEMORAL (In Hunter's Canal). 

Position. — The position is the same as before. 
Incision. — Three inches in the line of the artery in the middle third 
of the thigh. Divide the skin and superficial fascia. Avoid the in- 

Tihialis anticus 




di^Uorurn 



Fig. 458.^Ligation of the anterior tibial artery. The nerve lies to the 
fibular side. (MouUin.) 

ternal cutaneous nerve and the long saphenous vein. Divide the deep 
fascia, expose the sartorius and draw it inward. Incise the roof of 
the canal but do not wound the long saphenous nerve which is just 
beneath. Draw it inward and expose the sheath of the vessels. 



ANTERIOR TIBIAL (Middle Third). 

Position. — Thighs extended, leg turned inward and the foot extended 
to indicate the position of the tibialis anticus muscle. 

Incision. — Four or five inches long in the line drawn from the head 
of the fibula to the middle of the front of the ankle-joint (Fig. 458). 
Expose the fascia. Divide it in the same line. By the sense of touch 
locate the septum between the tibialis anticus and extensor longus 
digitorum. Flex the foot to permit the separation of these muscles 



LIGATION OF THE POSTERIOR FIBIAL. 



593 



and follow the septum down to the artery. The nerve is to the front 
and outer side. Pass the ligature from without inward. 

ANTERIOR TIBIAL (Lower Third). 
Position. — Same as above. 

Incision. — Locate the tendon of the tibialis anticus; along its external 
border divide the skin for three inches. Find the septum between 




Fig. 459. — Ligation of the posterior tibial artery. The gastrocnemius retracted; 
she soleus divided. (MouUin.) 

the tibialis and the extensor proprius hallucis. In this space lies 
the artery with the nerve to the front and outer side. Pass the liga- 
ture from without inward. 

DORSALIS PEDIS. 

Position. — ^Patient on back with foot extended and resting on heel. 

Incision. — Two inches long beginning at the middle of the lower 
border of the annular ligament. Expose and separate the tendons of 
the extensor proprius hallucis and extensor longus digitorum; the 
artery is seen lying upon the tarsal ligaments. The nerve lies to the 
fibular side. Pass the ligature from without inward. 

POSTERIOR TIBIAL (Middle Third). 
Position. — ^Patient on back; leg and thigh flexed; thigh rotated out- 
ward so that leg lies on its outer side (Fig. 459). 

Incision. — Four inches long, along the line three-fourths inch be- 
38 



594 SUTURE AND LIGATION OF ARTERIES. 

hind the internal border of the tibia. Expose and divide the deep 
fascia. Expose and develop the inner border of the gastrocnemius; re- 
tract and thus expose the soleus attached to the inner border of the tibia. 
Divide the soleus vertically, and at the bottom of the wound is seen the 
yellow fibrous aponeurosis which covers the vessels and deeper layer 
of muscles. Divide the aponeurosis about one and one-half inches 
from the internal border of the tibia and expose the artery. Draw the 
nerve to the outer side and pass the ligature from without inward. 



P 



Fig. 460. — Ligation of the posterior tibial behind the ankle. (MouUin.) 

POSTERIOR TIBIAL (At the Ankle). 

Position. — Turn the foot on its outer surface (Fig. 460). 

Incision. — Curved, three inches long, with center midway between 
malleolus and the inner tuberosity of the os calcis. Divide the fascia 
and the internal annular ligament cautiously. The artery is just be- 
neath the ligament. Separate the veins and pass the ligature from 
without inward. 



CHAPTER XXL 
SOME PRACTICAL AMPUTATIONS. 

The primary aim of "an amputation is to conserve the life or health 
of the patient; the secondary aim is to conserve, as much as possible, 
the function of the member. The first requires that as much as neces- 
sary be removed; the second, that no more than necessary be removed. 
The good surgeon will always adjust and harmonize these two prin- 
ciples and they will determine the time and technique of the particular 
operation. 

The time element is of especial concern in traumatism and gangrene, 
for if the operation is done too early, too much may be removed in 
the one case and too little in the other. In traumatism, tissue that at 
first sight seemed beyond remedy, may survive; in gangrene, tissue 
that seemed viable may be left, only to necessitate another dangerous 
operation; so that following traumatism, it is better not to operate 
until the limit of the devitalized tissue has been definitely determined; 
and in the case of gangrene, until the line of demarcation has definitely 
formed. 

The technique is principally concerned with conservation of function, 
and looks to the formation of a good stump. ''A stump to be service- 
able, should be sound, unirritable, with good circulation and abundant 
leverage" (Bryant, Operative Surgery). To produce a stump with 
these qualities requires prevision of the flaps particularly; their shape, 
length, and vascularity. Upon their shape will depend the position 
which the cicatrix will ta.ke; upon their length, the comfortable ad- 
justment of skin and bone; upon their vascularity, the prompt repair, 
proper nutrition and subsequent freedom from disease. 

The cicatrix should fall where it will be least subject to pressure and 
friction, wherever that may be done without the sacrifice of useful 
tissues. In determining the position of the cicatrix, one must then 
consider the occupation of the patient, and the possibility of an arti- 
ficial limb being worn. 

595 



596 SOME PRACTICAL AMPUTATIONS. 

In the case of the leg, for example, the greatest tension might fall 
on the end of the stump, and a scar there be some source of annoyance; 
in the case of an arm, more pressure might fall on the side, from arti- 
ficial appliances, and an end scar would therefore be more satisfactory. 
Nerves likely to be pinched up in the cicatrix should always be resected. 
The ends of severed tendons should likewise be resected, but not so 
high that their empty sheaths may be left to favor the lodgment of 
infection. 

That the stump may be sound and uniform in its outline, it is neces- 
sary that the different degrees of contractility of the various groups of 
divided muscles be known and their division accomplished accordingly, 
so that finally their ends may occupy the same level. The bones must 
also be sawed squarely and care taken that the division is not com- 
pleted by fracture. The periosteum, also, must not be too roughly 
handled. 

The technique is concerned also with the prevention of hemorrhage. 
This is best secured by first elevating the limb for several minutes and 
then applying an Esmarch tube above the site of the operation. 

After the section of the limb is completed and the large vessels se- 
cured and ligated, the tube must be removed and each bleeding point 
ligated separately. The tube has the disadvantage that there is nearly 
always a temporary vasomotor paralysis due to the pressure, and on 
that account, the oozing is considerable. 

The occasional surgeon will be called upon to do amputations under 
two entirely different circumstances, and his mode of procedure will 
be quite different in the two cases. In the one case, he will attempt 
the typical amputation of the text-book; in the other, his sole guide 
will be the preservation of tissue; he will do an atypical amputation. 

(A) The soft parts are more extensively destroyed than the 
bone. This is nearly always the case in traumatism and always the 
case in gangrene. The site of amputation will depend upon the limit 
of the sound skin; the rule is to remove none of the healthy soft parts; 
the line of incision should follow the line of demarcation, and having 
fashioned the flap following this indication, divide the bone high enough 
to accommodate the flaps, and no higher. (See also injuries to the 
extremities.) 



AMPUTATION OF FINGERS. 597 

(B) In case the bone is more extensively destroyed than the soft 
parts, as in tuberculosis, sarcoma, etc., one has more option; he can 
fashion the flaps in any manner desired, for usually much that is healthy 
will have to be removed. The position of the cicatrix can be determined 
and such is the typical amputation. 

FINGER AMPUTATIONS. 

Practical anatomical points (Jacobson, Operative Surgery): 
"The three creases in front almost correspond to the joints. The 
lower crease is just above the joint; the middle is opposite the joint; the 
highest, nearly three-quarters of an inch distal to the metacarpo-pha- 
langeal joint. 

"The prominence of the knuckles is formed by the higher of the two 
bones; by the head of the metacarpal bone, the head of the first phalanx, 
the head of the second phalanx for the three joints respectively. 





Fig, 461. — ^Typical amputation of finger; palmar flap, dorsal scar. (Farabeuf.) 

"The joint in each case is below, or distal to, the prominence; the 
metacarpo-phalangeal joint is about one-third inch below the knuckle; 
the second joint, one-sixth inch below the knuckle; the terminal joint 
one-twelfth inch beyond the knuckle. 

"In the distal and interphalangeal, the joint is concave from side 
to side and presents a concavity toward the finger tips. In the meta- 
carpo-phalangeal joint, the convexity is toward the finger tip. 

"From the readiness with which the tendons conduct infection, care 
should be taken to keep even so small an amputation as that of a finger 
strictly sterile and in amputating through damaged parts, the flaps 
should not be too closely united with sutures." 

It is a rule with but few exceptions, to save as much of the finger as 
possible, and it will almost always happen in removing part of a finger, 
that an atypical amputation will be indicated. Let the scar fall where 



598 



SOME PRACTICAL AMPUTATIONS. 



it will, making a dorsal or a lateral flap if necessary. The palmar 
flap and dorsal scar is ideal, but rarely attainable (Fig. 461). There 
are, however, surgeons of large experience who insist that a palmar 
flap be secured even at the cost of more finger, and that less than half a 
phalanx should not be saved but cut back to the joint to avoid flexure. 
(See injuries to the hand.) 

If a distal phalanx is to be removed, begin by pronating the hand, 
forcibly flex the phalanx and divide the skin one-half inch distal to 




Fig. 462. — ^Atypical amputation of a finger, the bone projecting beyond 
the skin. Dorsal incision. (Veau.) 

the knuckle; this incision deepened will open the joint. Divide the 
lateral ligaments. The edge of the knife is carried under the phalanx 
and swept downward, grazing the bone and cutting with a steady 
sawing movement. The result is indicated in Fig. 461. Do 
not cut the flap too short, a common mistake with the inexperienced. 

AN ATYPICAL AMPUTATION. 

Suppose a finger to have been sawed off. The bone projects be- 
yond the retracted skiii. It is not possible to fashion a flap without 
removing some bone. 



ATYPICAL FINGER AMPUTATION. 



599 



Local anesthesia (Figs. 7 and 8). Circular constriction at the 
base will control bleeding and prevent rapid absorption of the solution. 
Begin by making a dorsal linear incision an inch long down to the 
bone (Fig. 462). 

Liberate the whole circumference of the bone one-third inch up, 
either with a rugine or a bistoury (Fig. 463) and at that level divide the 
bone with bone forceps (Fig. 464). Employ two or three sutures with 
drainage if there is much chance of infection (Fig. 465). 





Fig. 463, — Liberating the bone. 
(Veau.) 



Fig. 464. — Section of the bone. (Veau.) 



If the dorsal linear incision opens into a joint, the section may be 
made there — disarticulate. 

Divide first the dorsal ligament, then the lateral ligament to the left, 
and as the phalanx is twisted toward the left, divide the lateral ligament 
to the right. Suture as before. It may be necessary to slice off the 
head of the remaining portion of the digit, if it is too prominent. 



TYPICAL AMPUTATION OF THE WHOLE FINGER. 

General anesthesia is usually necessary. The method of pro- 
cedure is different for the middle and ring fingers, the index and little 
fingers, and the thumb. 



6oo 



SOME PRACTICAL AMPUTATIONS. 



(I) The Middle and Ring Fingers. — Locate the articular line by 
making traction on the finger with one hand and palpating each side 
of the joint with the index finger and thumb of the other hand. 




Fig. 465. — Atypical amputation: Suture and drainage. (Veau.) 




Fig. 466. — Typical amputation of middle finger: Primary incision directed 
to the right. (Veau.) 

Begin the incision at the upper level of the joint; carry it obhquely 
downward and forward between the fingers so that it reaches the 
palmar surface at the right, a little below the crease (Fig. 466). 



AMPUTATION OF THE MIDDLE FINGER. 



60 1 



Lift up the hand so that you face the palm and cut transversely 
to the left (Fig. 467). Now lower the hand and complete the in- 
cision, bringing it obliquely upward and backward to the knuckle, 
the starting point (Fig. 468). 

Having outlined the incision in this manner, repeat the movement, 
cutting to the bone. Retract the flap, exposing the articulation. 




Fig. 467. — Amputation of the middle finger: Lifting the hind while 
making the transverse, palmar incision. (Veau.) 



Disarticulate. Pull on the finger to separate the joint surfaces, 
which helps to locate the joint line. Hold the bistoury vertically, 
and with its point, divide the lateral ligament to the left, then the 
dorsal ligament (Fig. 470), then the ligaments to the right, at the 
same time bending the finger to the right. 

Tie the digital arteries, usually one on each side and suture (Fig. 469). 

(II) Index and Little Fingers.— In these two instances, the aim 



6o2 



SOME PRACTICAL AMPUTATIONS. 



is to carry the scar toward the dorsum and the axis of the hand. In 
the case of the index, it falls toward the ulnar side; in the case of the 




Fig. 468. — Amputation of the middle finger: Completing the 
skin incision. (Veau.) 




Fig. 469. — Amputation of the middle finger: Traction on the finger while the bistoury 
cuts first the left and then the dorsal Hgaments. (Veau.) 

little finger, toward the radial side. The scar is, then, in each case, 
furthest removed from pressure. 

The flap itself, of rounded outline, folds over on an axis passing 



AMPUTATION OF THE LITTLE FINGER. 



603 



obliquely through the joint cavity and approximates the adjoining 
finger. 

In the case of the little finger, begin the incision just below the joint 
line on the ulnar side of the extensor tendon, and carry it obliquely 
downward and forward and then across the palmar surface, inscribing 




Fig. 470. — Amputation of the middle finger completed. (Veau.) 



a regular semicircle which ends at the free border of the web between 
the little and ring fingers. Complete the incision by cutting from this 
point to the starting point, inscribing a semicircle with its concavity 
toward the web. Follow this same track again, cutting to the bone. 
Denude the bone completely (Fig 471). You will observe that the ex- 
tensor tendon is difficult to divide and requires especial attention. 
Disarticulate. Pull on the digit to expose the joint line and divide 



6o4 



SOME PRACTICAL AMPUTATIONS. 





Fig. 471. — Amputation of the little finger: Fig. 472. — Amputation of the little finger: 
Flaps completed. (Veau.) Disarticulation, cutting from left to right. 

(Veau.) 





Fig. 473. — Amputation of the little 
finger: Flap after disarticulation. 
(Veau.) 



Fig. 474. — Amputation of the little 
finger: flap sutured. The line of union 
lies toward the axis of the hand on the 
dorsum. (Veau.) 



AMPUTATION OF THE INDEX FINGER. 



605 



the lateral ligaments to the left and then the dorsal, facilitated by- 
slight flexion. 

Next, rotate the finger to the left and divide the lateral ligaments to 
the right. The joint is completely opened and the rest is easy (Fig. 472). 
The appearance of the flap is indicated in Fig. 473. Employ three 
or four interrupted sutures (Fig. 474). 





Fig. 475. — Amputation of index; 
showing form of flap. (Veau.) 



Fig. 476. — Amputation of index and little 
fingers completed. (Veau.) 



The removal of the index finger is conducted along the same lines. 

The first semicircular incision is carried around the radial side and 
completed by a second, following the web of the finger. The appear- 
ance of the flap is indicated in Figure 475, and the final result in Fig. 476. 

If the patient is a laborer, it is necessary to render the hand as 



6o6 



SOME PRACTICAL AMPUTATIONS. 



useful as possible, nor must the cosmetic effect be neglected. It is 
necessary to reduce the size of the heads of the metacarpal bones. 
The head of the metacarpal bone of the index is best reduced by an 
oblique section of the radial side; of the little finger, the ulnar side; 
of the ring finger, by transverse section (Fig. 477). With regard to the 
middle finger, the head of its metacarpus should not be removed 
unless shapeliness rather than strength is desired (see page 88). 




Fig. 477. — Lines of section of the metacarpal heads. (Veau.) 



ATYPICAL AMPUTATION OP THE ENTIRE PINGER. 

In the case of the ring or middle finger mashed off near the meta- 
carpo-phalangeal joint, it is useless to try save the stump as its presence 
will be an actual hindrance to the other fingers. 

Disarticulate. Make a dorsal incision (Fig. 478), extending a 
centimeter above the metacarpal head. Raising the finger and 
cutting from left to right, carry the incision around the base near the 
limit of the sound tissue (Fig. 479). 

Denude the bone, exposing well the metacarpal head and hold the 



AMPUTATIONS OF THE THUMB. 607 

flaps well back out of the way. Divide the tendons in the manner al- 
ready indicated for the amputation of the finger (Fig. 480). Steady 
the head of the bone and pinch off with a bone forceps (Fig. 481). 

(Ill) The Thumb. — The thumb must be treated with the utmost 
conservatism. The smallest part must never be removed unneces- 
sarily as it is almost as useful as the rest of the fingers together and 




Fig. 478. — Crush of ring finger requiring a typical amputation. Dorsal incision to 
expose articulation, (Lejars.) 

nearly always after a traumatism, it is best to do an atypical amputa- 
tion. 

In the typical amputation, employ a palmar flap. Begin on the 
dorsal surface just below the articular line and incise to the right, 
reaching the edge of the palmar surface just above the interphalangeal 
crease. 

Now go back to the starting point and make an incision to the left, 



6o8 



SOME PRACTICAL AMPUTATIONS. 



similar to the first, and complete it by a transverse incision joining the 
first. The "U" shape is indicated (Fig 482). 

Repeat the incision, cutting to the bone, and dissect up the flap. 
Strip back all the soft parts down to the joint, while an assistant holds 
the thumb. 

Disarticulate. Take hold of the thumb again and direct the as- 




Fig. 479. — Atypical amputation of the entire finger: Anterior circular incision. (Lejars.) 



sistant to retract the flaps. Make strong traction and cut the liga- 
ments to the left, above, and then to the right, twisting the thumb 
to make them tense. Suture. 

AMPUTATION OF A FINGER AND ITS METACARPAL. 

Typical amputation (infrequent): 

(i) Middle and Ring Fingers. — Begin the' incision over the carpo- 
metacarpal line (on the line drawn between the bases of the metacarpals 
of the thumb and little finger) and descend along the bone; follow the 



SOME PRACTICAL AMPUTATIONS. 



609 




Fig. 480. — Atypical amputation of the entire finger: Disarticulation. (Lejars.) 




Fig. 481. — Atypical amputation of the entire finger: Resection of the head 
of the metacarpus. (Lejars.) 

39 



6io 



SOME PRACTICAL AMPUTATIONS. 



web, cross the palmar surface and ascend to the starting point 
(Fig. 483). 

Denude. This is sometimes difi&cult. Dividing all the tissues 
around the head of the metacarpal, work up and toward the wrist, 
remembering particularly that the deep palmar arch crosses the 
middle of the bone and is in touch with it. It must not be injured. 

Disarticulate by dividing the bone at its base with a bone forceps. 

(2) The Index and Little Fingers. — The procedure is the same as 
before except that the incision on the side opposite the axis of the hand 








Fig. 482. — Line of incision for amputa- 
tion of thumb. (Farabeiif.) 



Fig. 483. — Lines of incision for remov- 
ing index and ring fingers and their cor- 
responding metacarpals. (Veau.) 



extends below the level of the web, in order that on that side the flap 
may be longer so that the seam will fall away from the margin of the 
hand. 

(3) The metacarpal of the thumb may be regarded as a finger; 
make the same sort of racket incision. Save all of the metacarpal 
possible (Figs. 484, 485, 486). 

Atypical Amputation of the Hand. — (Traumatism of the metacar- 
pals) (Fig. 487). 

It is often inadvisable to amputate at once, for parts that seem 
devitalized may survive. 



AMPUTATION OF THE HAND. 



6ll 



Secure hemostasis and carry out a most rigorous disinfection, 
suture with ample drainage and wait the course of events ; the limits of 
viable tissue can soon be determined. Amputate before gangrene sets 
in. Rather, as Lejars says, you do not amputate but trim up. It is 
the rule to remove the projecting bone without any regard to a typical 
amputation. 





Fig. 484. — Crushing injury destroy- 
ing thumb. Part of its metacarpal to 
be saved. (Lejars.) 



Fig. 485. — Denuding metacarpus preparatory 
to its section. (Lejars.) 



Denude the bone as far back as the skin flaps demand (Fig. 488). 
Use bone forceps (Fig. 489). Suture loosely with ample drainage 
(Fig. 490). Apply a moist dressing, which is to be changed daily and 
if the temperature rises, remove the sutures and give the hand a pro- 
longed immersion in hot normal salt solution and renew the dress- 
ings. Similar amputation, thumb saved (Fig. 491). 



6l2 



SOME PRACTICAL AMPUTATIONS. 

AMPUTATION OF THE FOREARM. 



Disarticulation at the wrist is very rarely done in general practice. 
If a tuberculosis of the wrist calls for intervention, amputate the fore- 
arm (Fig. 492). 

Following traumatism, do an atypical amputation conserving as 
much as possible of the member. 




Fig. 486.- 



- A typical amputation of the thumb complete; part of metacarpus 
preserved. Drainage. (Lejars.) 



Typical amputations of the forearm are most easily performed at 
any level, by a modified circular incision; the dissection of the cuff is 
facilitated by two lateral vertical incisions if at the level of the section 
the member is conical. Determine first where you propose to divide 
the bone. The section of the skin must fall some distance below that 
of the bone. The section of the bone should be made about the 
distance equal to the diameter of the limb, above the skin section. 



SOME PRACTICAL AMPUTATIONS. 



613 




Pig. 487.— Injury to hand. Useless to try to save any but the index finger. (Veau.) 




Fig. 488. — The metacarpals are denuded upward for an inch; all the 
soft parts saved. (Veau.) 



6i4 



SOME PRACTICAL AMPUTATIONS. 



Circular Incision. — Begin by dividing the skin in front (Fig. 493), 
and complete the circle posteriorly (Fig. 494). Divide nothing but 
the skin and fascia. 

Lateral incisions are to be made extending upward two or three 
fingers' breadth (Fig. 495). 

Transfix. Direct the assistant to hold the hand supinated and 
flexed to relax the flexor muscles, while the point of the knife is intro- 




FiG. 489. — Section of metacarpals with bone cutting forceps. (Veau.) 



duced laterally at the upper end of the nearest vertical incision (Fig. 
496). Elevate the point of the knife as it approaches the bone so that 
it grazes over the bone. Drop the point into the interosseous space 
and elevate again as it comes in contact with the second bone. When 
it emerges at the opposite side at the same level, the knife is swept 
downward, its cutting edge held close to the bones, and the tissues are 
cleanly divided longitudinally, until the level of the circular skin in- 



SOME PRACTICAL AMPUTATIONS. 615 

cision is reached, \Yhen the blade is made abruptly to cut toward the 
surface (Fig. 497). As the section toward the surface is made, the 
assistant should extend the hand slightly, the tense tendons being 
more easily divided. 

Pass the blade posteriorly in the same manner and as the knife cuts 




Fig. 490. — Amputation completed. (Veau.) 

toward the surface, the hand should be flexed. The muscles which 
fill in the interosseous space as well as those which are closely attached 
to the bones, are yet to be divided. Figure 498 indicates the manner 
in which this is accomplished. The interosseous membrane re- 
quires special attention. 

Denude the bones of periosteum from below upward (Fig. 499.) 



6i6 



SOME PRACTICAL AMPUTATIONS, 




Fig. 491. — Ampu- 
tation of the hand. 
Thumb saved. (Senn.) 



The adjacent surfaces of the bones are especially 
difficult to denude, but take the time for it. Pass 
a sterile compress between the two bones and one 
on either side to act as retractors while the bones 
are sawed. 

Saw the bones at the level of the periosteal 
flaps. Notch the ulna first, then completely divide 
the radius and finally the ulna. 

The median nerve will be found in the midst 
of the muscles of the anterior flap and the ulnar 
internally; the posterior interosseous is more diffi- 
cult to find posteriorly. Resect them high enough 
to escape the scar. Draw the periosteal flaps over 

the end of the bones and if desired, they may 

be sutured with catgut. Suture the skin and 

muscle flaps and, if necessary, drain (Fig. 500). 

AMPUTATION AT THE ELBOW JOINT. 

Make a circular incision three inches below 
the joint, involving the skin and fascia. Turn 
back the cuff to the joint. Divide the muscles 
over the joint line. Divide the lateral liga- 
ments. Open the outer side of the joint first 
and directing the assistant to make traction 
on the arm, separate the ulna and divide the 
triceps. Tie the arteries, resect the nerves, 
and suture. 

AMPUTATION OF THE ARM. 

Apply an Esmarch tube high up near the 
axilla, or an assistant may compress the artery 
in the upper part of the arm or behind the 
clavicle. 

Stand to the outer side of the arm. ^ Retract 
the skin with the left hand if operating on the pj^. 492.— Amputation 
right arm, or dkect the assistant to retract the fisi? of ^thl wrist. (vfauT" 




SOME PRACTICAL AMPUTATIONS. 



617 




Fig. 493. — Amputation of the forearm: Beginning the circular incision. (Veau.) 




Fig. 494. — Amputation of the forearm: Completing the circular incision. (Veau). 



6l8 SOME PRACTICAL AMPUTATIONS. 

skin if operating on the left arm. The skin section must lie about one 
diameter below the proposed bone section (Fig. 501). 

Divide the tegument and fascia anteriorly first and then posteriorly. 
When dividing internally, remember that the artery is quite superficial. 
If a long blade is used, the complete incision of the skin may be 
accomplished by a single circular sweep; the hand carrying the knife 
is passed under the limb until the heel of the knife rests on the top of 
the limb, and then with slight sawing movements, the knife is made to 




W 

Fig. 495. — Lateral incisions. (Veau.) 

encircle the arm, dividing the skin successively above, internally, 
below, externally, and above again, reaching the starting point. It 
may be necessary to make the pass a second time to divide the fascia. 

Retract the skin freely; it may be necessary to free the fascial attach- 
ments with the point of the knife. Do not "button-hole" the flap. 
The adhesions are most marked internally, over the artery. The 
divided skin retracts about one and one-half inches (Fig. 502). 

In the meantime, there is considerable venous hemorrhage. 

Divide the muscles by a circular sweep at the level of the retracted 



SOME PRACTICAL AMPUTATIONS. 



619 




Fig. 496. — Transfixion. (Veau.) 




Fig. 497.— Completing the anterior flap, cutting outward following transfixion. (Veau.) 



620 



SOME PRACTICAL AMPUTATIONS. 



skin, cutting to the bone (Fig. 504). If a scalpel is used, cut internally 
last, so that the artery is last divided. Work fast, for the bleeding 
will be free. 

Divide the muscles a second time, for the first section finds them 
retracting unequally. Divide them at the level of the retracted skin 
(Fig. 505). Be sure that all the soft parts are divided. Catch up the 
bleeding points and then denude the bone for an inch (Fig. 506). 

Retract the flaps with sterile compresses and saw the hone as high as 
the flaps will permit. 




Fig. 498. — Lines of incision to complete section of the soft parts. (Farabeuf.) 



Begin the section with the heel of the saw on the bone steadied by 
the thumb; take care, at the end, not to sliver the bone. 

Tie the brachial artery and then the veins with strong catgut; 
finally tie all of the smaller vessels. Suture the muscles first over the 
end of the bone, and then suture the skin. 

AMPUTATION AT THE SHOULDER JOINT. 

Amputation at the shoulder may be performed by a variety of 
methods, each of which has its advantages and disadvantages. 
The special points to be thought of in making the operation are the 
control of hemorrhage, good drainage, easy disarticulation and a good 
stump. No one operation, perhaps, secures all of these principles in 
equal degree. 

Spence's method is recommended as generally serviceable, 
Recall the principal landmarks of the shoulder joint, the acromion 
process, the coracoid process, the tuberosities; recall the attachments 
of the various muscles; and the relations of the blood vessels. 



AMPUTATION AT THE SHOULDER. 



621 



The patient is placed with his shoulder close to the edge of the 
table, with shoulder elevated, and face turned to the opposite side. 
The operator stands to the outer side. 

The operator aims at the exposure of the joint and disarticulation 
and finally the formation of an axillary flap. 

Incision. — (i) Begin just in front of the coracoid process and cut 
vertically downward to the lower level of the tendon of the pectoralis 




Fig. 499. — Stripping back the perios- 
teum with the rugine. (Veau.) 



Fig. 500. — Amputation complete. Trans- 
veise drainage. (Veau.) 



major, keeping in front of the groove between the pectoralis major 
and deltoid. This incision should reach the bone; the pectoralis 
major tendon is divided. The bleeding comes from the humeral 
branches of the acromio-thoracic and from the anterior circumflex. 
These vessels may be clamped. 

(2) Next carry the incision outward across the arm, making a slight 
curve, convex downward, and ending at the axillary border. All the 



622 



SOME PRACTICAL AMPUTATIONS. 



structures are divided to the bone. The deltoid is divided just 
above its insertion and the hemorrhage comes from the muscular 
branches. 

The next step consists in outHning the internal flap by making an 




Fig. SOI. — Circular section of the skin. (Veau.) 



oval skin incision, which extends from the termination of the first 
across the inner surface of. the abducted arm to the end of the vertical 
part of the first incision (Fig. 506). 

The third step consists in elevating the external flap which contains 
the deltoid. It is easily dissected and by this means the joint is ex- 



AMPUTATION AT THE SHOULDER. 



623 



posed. The posterior circumflex artery must not be injured and is 
preserved in the deltoid flap. 

The fourth stage: Disarticulate. Begin by dividing the biceps 
tendon and the capsule with a transverse cut. Rotate the arm in- 
ward and divide successively the tendons of the teres minor, the in- 
fraspinatus, the supraspinatus; rotate the arm outward and divide the 



\^- 




Fig. 502. — Freeing the skin flap. (Veau.) 



tendon of the subscapularis. If the humerus has been broken, rotate 
the head by means of a bone forceps. 

Dislocate the head, divide the capsule behind and push the head up 
to the level of the acromion; drawing the head outward, sKp the knife 
behind the head and prepare to complete the section of the soft parts. 
If the axillary has not been previously ligated, the assistant grasps the 



624 



SOME PRACTICAL AMPUTATIONS. 



upper part of the flap about to be divided and his hands follow the 
knife downward, ready to compress the artery as soon as divided. 

The knife follows the bone till opposite the skin incision when it 
cuts directly through the soft parts that the vessels may not be divided 
obliquely. The arm is now completely removed. 




Fig. 503. — First circular incision of the soit parts. (Veau.) 



The next step consists in ligating the vessels and in trimming the 
axillary nerves and in suturing the flaps so as to form a vertical scar 
as nearly as possible. The glenoid fossa may be curetted. 

For the control of hemorrhage, Wyeth's plan of constriction may be 
followed. An elastic ligature held in place by two'pins passed through 
the soft parts before and behind the shoulder compresses the axillary 
vessels. 



SCAPULO-HUMERAL AMPUTATION. 625 

AMPUTATION ABOVE THE SHOULDER. 

This operation, bloody and often fatal, may need to be undertaken 
for malignant disease in the vicinity of the shoulder joint or as an 
emergency in the case of crushing injury to the shoulder or of gun- 
shot wounds. 

The procedure as defined by Berger contemplates the resection of 
the middle third of the clavicle and ligation of the subclavian; the 





Fig, 504. — Second circular incision of soft 
parts at level of retracted skin. (Veau.) 



Fig. 505.- 



-Denuding periosteum with 
rugine. (Veau.) 



formation of the antero-inferior and a postero-superior flap; and 
finally the division of the muscles connecting the scapula with the trunk. 

The operation is thus described: 

Place the patient on his back close to the edge of the table, with the 
shoulder slightly elevated. Begin the incision over the clavicle at the 
outer border of the sterno-mastoid, and follow the clavicle outward to 
the acrominal end, cutting to the bone. Denude the middle third of 
its periosteum with the rugine, and divide the bone at the junction of 
the inner and middle thirds. Elevate the bone and divide again at 
the junction of the middle and outer third. Separate by blunt dis- 
40 



626 



SOME PRACTICAL AMPUTATIONS. 



section the fascias overlying the subclavian vessels and first ligate 
the artery at the outer border of the first rib and then the vein. 

Now change the patient's position; the shoulder is brought over the 
edge of the table, the arm abducted, and the head turned to the oppo- 
site side. 

Form the antero-injerior flap. Begin an incision at the middle of 
the first and carry it obliquely downward and outward; just to the 
outer side of the coracoid process, along the anterior border of the 
deltoid, to the axillary border and thence across the inner surface of 
the arm just below the axillary fold and 
thence down the axillary border of the 
scapula. Divide the pectorals and the latis- 
simus dorsi close to their insertions. Resect 
the nerves of brachial plexus. 

Form the postero- superior flap. Begin the 
incision over and just internal to the acromo- 
clavicular joint and carry it downward over 
the spine of the scapula to the lower angle of 
the scapula, where it joins the preceding 
incision. Dissect the flap and expose the 
muscles. Divide first the trapezius and then 
with heavy scissors divide close to the bone, 
the muscles attached to the posterior border, 
the serratus magnus, the rhomboideus major 
and minor, and the levator anguli scapulae. 
Complete the hemostasis and drain through 
button-holes in the flaps in the axilla and scapular region. Bandage 
firmly so as to obliterate the cavities. 




Fig. 506. — Spence's amputa 
tion. (Moullin.) 

The arm falls away. 



AMPUTATION OF THE TOES. 

These amputations are more frequently consequent upon trauma- 
tism; occasionally for deformity or other painful conditions. 

In the amputation of fingers, as much as possible is saved; in the 
amputation of toes, the whole toe is nearly always removed. In 
consequence, these amputations are usually typical, for one does not 
so much need to concern himself with the conservation of tissue. 



AMPUTATION OF THE GREAT TOE.' 



627 



In the case of total ablation of the finger, a part of the metacarpal 
head must usually be removed to enhance function; the head of the 
metatarsals must always be saved, where possible, to preserve the func- 
tions of the foot. 

The position of the cicatrix demands more attention in the case of 
the toes. A special effort must be made to leave the scar farthest 
from pressure, that is, dorsal and to the inner side with reference to 
the axis of the foot. 

Local anesthesia is often sufficient, forming an anesthetic ring around 
the entire toe, involving the skin. The injection may need to be renewed 
for the deeper tissues; and before disarticulation, inject the joint. 

AMPUTATION OF THE GREAT TOE. 

In amputation of the great toe, the flap resembles that of the index 
finger and the scar adjoins the base of the second toe. 

Begin by locating the joint line. The incision commences just below 






Fig. 507. — Lines of incision for am- 
putation of big toe. (Farabeiif.) 



Fig. S08. — Amputation of big 
toe completed. (Farabeuf.) 



Fig. 509: 



this, and over the tibial border of the extensor tendon, and extends 
with a slight outward convexity, downward and forward to the inter- 
phalangeal crease on the plantar surface and across the palmar 
surface obliquely, ending at the web. 

Begin on the dorsum again at the original starting point and with a 
slightly curved incision, join the ends of the first (Fig. 507). 



628 



SOME PRACTICAL AMPUTATIONS. 



Dissect the -flap, keeping close to the bone, so that all the soft parts 
shall be preserved in the flap. Divide the flexor tendon — sometimes 
rather difl&cult. 

Disarticulate. Divide, first, the lateral ligaments to your left, then 
the dorsal, and finally those at your right. Divide the plantar liga- 
ments, twisting the toe, as in the case of the finger. Employ drainage; 
pull the flap into position and suture. The shape of the flap and the 
position it assumes are represented in Figures 508 and 509. 

AMPUTATION OF THE LITTLE TOE. 

Incision. — Begin at the inner end of the joint line and cut obliquely 
downward and outward, meeting the plantar surface at the joint line 
below, and then backward and inward toward the web (Fig. 510). 




Fig. sio. Fig. 511. 

Amputation of the little toe. (Farabeuf .) 



Fig. 512. 



In this manner a convex flap is formed (Fig. 511). Dissect the flap, 
preserving in it, all the soft parts. Expose the joint line. 

Disarticulate. Making vigorous traction on the toe, divide in reg- 
ular order the lateral, the dorsal, the lateral (to your right) and plantar 
ligaments. 

Drain from the upper part of the incision and suture. The position 
of the cicatrix is represented in Figure 512. 

AMPUTATION OF ONE OF THE MEDIAN TOES. 

Incision. — The line of the joint having been determined, begin just 
above it on the dorsum, incising forward and downward to just below 



AMPUTATION OF TOE WITH ITS METATARSUS. 



629 



the web, crossing the palmar surface and back to the starting point, 
completing the racket (Fig. 513). Remember that the metatarso- 
phalangeal joint is considerably above the line of the web. Denude 
and divide the flexor tendon. 

Disarticulate in the manner already described for the other toes. 
Drain from the upper end of the incision and suture (Fig. 514). 





Fig. 513. — Line of incision for 
amputation of toe. (Veau.) 



Fig. 514. — Suture and drainage 
after amputation. (Veau.) 



AMPUTATION OF A TOE WITH PART OF ITS 
METATARSUS. 

This amputation presents some difficulties in dissecting the flaps, 
because of the palmar projection of the head of the metatarsal. 

The incision is racket shaped, as in amputation of the toe, but it 
begins higher up, above the level of the diseased bone, and runs down 
to the web, across the palmar surface and back to the starting point, 
as represented in Fig. 515. To dissect the flaps for the middle toes, 
denude the dorsum of the metatarsus and divide it with the bone forceps, 
and lifting upon the divided end, dissect forward along the palmar 
surface. 

The metatarsus of the little and great toes may be sawed. In 



630 SOME PRACTICAL AMPUTATIONS. 

forming the flap for the great toe and its metatarsus (Fig. 516) do not 
forget to remove the sesamoid. Drain as in amputation of the toes, 
and suture. 




Fig. 515! — Lines of incision for removal of toes with head of 
corresponding metatarsals. (Veau.) 




Fig. 516. — Amputation of big toe with head of metatarsal. (Farabeuf.) 

AMPUTATION OF A PART OF THE FOOT. 

As in the case of the hand, the rule is to conserve as much as possible 
of the foot. 

In the case of traumatism or gangrene, where the soft parts are 
more involved than the bone, the line of section follows the healthy 



ATYPICAL AMPUTATION OF THE FOOT. 



631 



skin and the bone section will be made to accommodate itself to the 
skin flaps. 

Atypical Amputation. — If the case is one of tuberculosis, the bone is 
more involved than the skin, and one may determine the upper limit 
of the diseased bone and divide it there. In such a case, one may 





Fig. s 1 7. — Following the line of demarcation. 
Atypical amputation. (Veau.) 



Fig. 518. — Dividing the bones. 
(Veau.) 



fashion a palmar flap, and make a dorsal scar — the typical amputa- 
tion. But, as Veau says, do not concern yourself with the formal 
operations, such as a Lisfranc or a Chopart — excellent exercises on 
the cadaver — but saw the bones where you must, to remove all the 
disease. 



632 



SOME PEACTICAL AMPUTATIONS. 



In the case of gangrene or traumatism, then, divide the tissues to 
the bone, along the line of demarcation. 

The borders of the palmar and dorsal flaps must correspond to 
the borders of the foot (Fig. 517). Once the soft parts are divided, 




Fig. 519. — Suturing extensor tendons to 
skin flap. (Veau.) 



Fig. 520. — Suture and drainage. 
(Veau.) 



they should be retracted by dividing their attachments close to the 
bone, and the bones are divided high enough for the flaps to come to- 
gether (Fig. 518). 

In the case of tuberculosis make a transverse incision dorsally and 



I 



INCISION FOR TOTAL AMPUTATION OF THE FOOT. 633 

shape the long palmar flap by transfixion and cutting outward, or by 
cutting from without inward (Fig. 519). 

Suture the tendons to the periosteum or fibrous tissues. Resect 
the nerves and suture, using drainage (Fig. 520). 

TOTAL AMPUTATION OF THE FOOT. 

In total amputation of the foot, the exact procedure will depend 
chiefly upon the condition of the os calcis. If it is sound, Pirogoff's 
osteoplastic amputation is indicated. If the os calcis is diseased, 
Symes' amputation is indicated — a disarticulation at the ankle joint, 
with erasion of the malleoli. But one cannot always determine before- 




FiG. 521. — Line of incision for complete amputation of foot. (Veau.) 

hand the state of the os calcis and therefore an incision should be 
made which will permit either procedure after the os calcis has been 
examined. 

First Incision. — The first incision extends across the sole with one 
end at the tip of the external malleolus and the other a finger's breadth 
below the tip of the internal malleolus. (The internal malleolus does 
not extend quite so low as the external) (Fig. 521). 

An assistant elevates the limb; you seize the foot with the left hand 
and make this plantar incision from left to right; that is to say, in the 
case of the right foot begin the incision at the end of the outer malleolus 
and terminate it a finger's breadth below the internal. In the case 
of the left foot, begin at the internal and end at the external malleolus. 

Repeat the movement several times for there is always considerable 



634 



SOME PRACTICAL AMPUTATIONS. 



difl&culty in accomplishing complete section of the tendons, some 
of which are oblique to the line of incision, and others deep and im- 
bedded in grooves. 

Second Incision. — Connect the extremities of the first incision by a 
dorsal incision, which should be slightly convex forward toward the 
toes. This line crosses over the head of the astragalus. The foot 





Fig. 52 2. — Section of the lateral liga- 
ments. (Veau.) 



Fig. 523. — Clearing the upper and internal 
surfaces of the os calcis. (Veau.) 



should be lowered and the cut made from left to right. Extension of 
the foot will facilitate the division of the anterior tendons and liga- 
ments. 

Now, distinguish the head of the astragalus, and between it and the 
articular surface of the malleolus, pass the point of the knife and cut 
downward (Fig. 522). By this means, the lateral ligaments are divided. 

The posterior ligaments are divided by cutting along the upper 
surface of the os calcis (Fig. 523). The joint is now freely exposed 



pirogoff's amputation. 635 

and the os calcis may be brought into view and examined. In examin- 
ing the outer side, dissect back the soft parts for an inch, but not quite 
so far on the inner side. To be sure of the condition of the bone, its 
substance must be inspected. 

(A) Suppose the Os Calsis is Sound. — Grasp the foot firmly with 
the left hand, depress it and pull upon it at the same time, while the 
assistant retracts the flaps, which have been loosed from the sides of 
the bone. 

The flaps are held back by retractors on each side, which are slipped 
down with the progress of the saw, the assistant bracing his thumbs 
against the heel. 

The saw is started in the upper face of the os calcis, a finger's 



"^v 




Fig. 524. — Section of the os calsis. The saw directed downward and forward. The 
retractors slipped downward as the saw progresses. (Farabeiif .) 



breadth behind the astragalus in a manner to take off a slice from 
above downward and forward (Fig. 524). With the completion of 
this section, the foot is removed, and the posterior part of the divided 
OS calcis is left in the heel flap. 

The next step is to saw off the malleoli. Begin by completely de- 
nuding these processes of their covering, skin, fascia and tendons. 
Carry the denudation upward, a distance of two fingers' breadth be- 
hind; just above the level of the articular surface of the tibia, in 
front. The posterior tendons especially, are sometimes difficult to 
dislodge from their groove. 

The line of section being thus cleared, the heel flap is held well up 
toward the calf, out of the way, by the assistant, who also supports the 
leg in the horizontal position. 



6^6 SOME PRACTICAL AMPUTATIONS. 

It is well for the operator to steady the limb by seizing one of the 
malleoli with a bone-holding forceps. The saw enters just above the 
articular line in front, and emerges a full finger's breadth above that 
level (Fig. 525). If the section is not carefully made, the coaptation 
of the sawed surface of the os calcis to that of the tibia, may be im- 
perfect. 

Complete the hemostasis, bring the two bone surfaces together, and 
suture the anterior tendons to the fibrous covering of the under surface 




Fig. 525. — Parts removed in PirogofE's amputation represented in dark. (Veau.) __;j 

of the OS calcis, the better to fix this stump in position. If it is feared 
the bone will slip, one or two bone sutures may be employed. Suture 
the skin, usually employing drainage. 

(B) Suppose the Os Calcis is Diseased. — In case the os calcis is 
diseased, it must be entirely removed, instead of sawed. 

The left hand strongly flexes the foot, until the posterior end of the 
OS calcis points upward (Fig. 526), and as the point of the knife dissects 
the tissues off the left side, the foot is rotated to the right, and when 
working on the right side, rotated to the left; in this manner the os 



syme's amputation. 



637 




Fig. 526. — Denudation of the posterior surface of the os calcis. (Farabeuf.) 




Fig. 527. — Syme's amputation of the foot. (Farabeuf.) 



638 



SOME PRACTICAL AMPUTATIONS. 



calcis is finally enucleated, being careful to follow the bone closely 
and not to "button-hole" the flap. 

Remember the principal vessels are to the inner side and are to be 
lifted up with the flap. 

Especial care is required when the attachment of the tendo-achilles 
is divided; the bone must be shaved, for it is here practically subcutane- 
ous, and it is easy to puncture the flap. You may expect this stage to 
be tedious. 




Fig. 528. — Suture and drainage. (Veau.) 



Finally the foot will be removed (Fig. 527). 

Now denude the lower end of the bones of the leg, observing that 
the tendons in front are held down by their fibrous sheaths. In order 
to facilitate this dissection, sweep the point of the knife around the 
bone, keeping it in close contact with the bone. This dissection 
must be carried upward for an inch and the malleoli will be com- 
pletely exposed. 

Steady the leg with a bone-holding forceps, and saw the bones at 
the level of the cartilage. Begin by notching the tibia, then com- 



AMPUTATION OF THE LEG. 



639 



plete the section of the external malleolus and terminate with the 
section of the tibia. If some cartilage remains, it may be scraped off. 
Resect the nerves, suture and drain (Fig. 528). 






Fig. 529. — Knee flexed for 
" peg -leg." (Veau.) 



Fig. 530. — Artificial limb 
applied. (Vet u.) 



Fig. 531. — Amputation of 
leg. Lines of section of soft 
parts and bone. (Veau.) 



AMPUTATION OF THE LEG. 

The leg may be amputated at any level. Formerly, when suppura- 
tion was the rule, and the cicatrix was large, adherent and painful, 
prohibiting the use of artificial limbs, the "point of election" was high 
up. The knee was flexed and the patient made use of a "peg-leg," 
the weight falling on the patella (Fig. 529). 

With present methods, the scar is a matter of less concern and the 



640 



SOME PRACTICAL AMPUTATIONS. 



aim should be to amputate as low down as possible, to the end that the 
muscles may be preserved to render efficient an artificial limb (Fig. 530). 

In the case of traumatism and gangrene then, do an atypical ampu- 
tation, preserving carefully the sound tissue and dividing the bone to 
accommodate the skin flap. 

If the bone is involved to a greater extent than the skin, as in tuber- 
culosis, a typical amputation may be done. 





Fig. 532. — Loosening the attachments of 
the flap to the tibia. (Veau.) 



Fig. 533. — Dissecting up the muscles with 
the artery. (Veau.) 



There are numerous methods of amputating the leg, some appro- 
priate to one level and some to another, but for the sake of simplicity, 
but one need be described — one which may be used with fair success 
in any part of the leg. 

Incision. — Begin with a circular incision of the skin about two and 
one-half inches below the level of the proposed bone section (Fig. 531). 
This incision will divide the skin and aponeurosis. ~ If front, care- 



1 



AMPUTATION AT THE KNEE JOINT. 64 1 

fully separate the skin from the tibial ci;est (Fig. 532). Next divide the 
muscles at the level of the retracted skin. Divide the muscles com- 
pletely but make the incision oblique to the axis of the limb, so that the 
incision reaches the bone at a higher level than at the surface (Fig. 533). 

To be certain that all the muscles are divided, one may repass the 
bistoury, as in the forearm (Fig. 498). Next 
denude the bones with the rugine, reaching above 
the level at which the bones are to be sawed. 
This denudation is most difficult and tedious 
behind, on account of the fibrous attachments of 
various muscles. 

The interosseous membrane is to be detached 
by a few vigorous strokes with the rugine from 
below upward. Divide it at the level of the 
proposed bone section. ^^^.^.^^^ 

Retract the flaps with three gauze compresses, ^T^ n^ 

one passed between the bones, one applied in 

^ ;- J. i Y\G. 534. — Amputation 

front and one behind; all to be held firmly by the complete. Transverse 

•^ "^ drainage. (Veau.) 

assistant. 

Begin the sawing by notching the tibia, then completely divide the 
fibula and end with the section of the tibia. Plane off the projecting 
angle of the anterior border of the tibia, resect the nerves and ligate 
the bleeding points. Drain, suture the anterior muscular flap to the 
posterior and suture the skin (Fig. 534). 

AMPUTATION THROUGH THE KNEE JOINT. 

This operation should be done in preference to an amputation of 
the thigh. 

"The femoral artery having been controlled, the limb supported 
over the edge of the table and slightly flexed, the surgeon standing on 
the right side of either limb, marks out two broad lateral flaps as 
follows: his left thumb and index finger being placed, the former over 
the center of the head of the tibia, the latter at the corresponding 
point behind, opposite the center of the joint, he marks out (in the 
case of the right limb) an inner flap by an incision which commences 
behind at the index finger and runs down the back of tlie leg for three 
41 



642 



SOME PRACTICAL AMPUTATIONS. 



and one-half inches, and then, curves up to the thumb. A similar 
flap is shaped on the outer side. 

The inner flap must be slightly larger, in view of the large side of 
the inner condyles. 

The flaps consist of skin and fascia. When they have been raised 
to the level of the articulation, the ligamentum patellae is severed, 
allowing the patella to go upward. The soft parts around the joint 




Fig. 535. — Circular incision of the skin. (Farabeuf.) 



are then cut through with a circular sweep and the leg removed. In 
doing this, the limb being flexed to relax the parts and facilitate 
opening the joint, the semicircular cartilages will very likely be found 
encircling the condyles of the femur and are to be left in situ by divid- 
ing the coronary ligaments which tie them to the tibia. Resect the 
nerves, ligate the vessels, drain and suture." (Jacobson's Operative 
Surgery.) 



INCISIONS IN AMPUTATION OF THE THIGH. 

AMPUTATION OF THE THIGH. 



643 



Determine the level of the bone section. About the distance of one 
diameter of the limb below this level, describe a circular incision^ 
dividing the skin and fascia, which may descend a little further be- 
hind than in front, if desired. 

The patient's legs are drawn out well over the edge of the table, the 
well limb flexed and the injured one held by an assistant. The opera- 



I 




Fig. 536. — Liberating the skin flap. (Farabeuf.) 



tor stands to the outside. Another assistant encircles the thigh above 
the level of the incision, with his hands. If the conventional am- 
putating knife is used, begin (on the right thigh) by passing the 
knife under the limb and with its heel resting upon the upper surface, 
bring it in a circular sweep back around the thigh, dividing successively 
the integument of the internal, inferior and external surfaces. The 



1 



644 



SOME PRACTICAL AMPUTATIONS. 



position of the hand may be slightly changed and the incision continued 
up over the anterior surface; or that may be divided by a second 
movement (Fig. 535). 

In the meantime, the left hand has steadied the skin; the assistant 
now retracts it while its fibrous attachments are loosened (Fig. 536) 
until there is a separation of at least three fingers' breadth. At the 




Fig. 



-Second circular section of the soft parts. (Farabeuf.) 



level of the retracted skin, divide the muscles as the skin was divided, 
aiming to reach the bone. But the divided muscles do not equally re- 
tract, and a second circular incision of the muscles at the level of the 
retracted skin is necessary to insure a uniform stump (Fig. 537). 

Denude the femur beyond the level of the proposed bone section. 
Direct the assistant to retract the flap wdth two lateral compresses or 
retractors. 



senn's amputation at the hip. 645 

Saw the femur, ligate all vessels likely to bleed, suture the muscles 
over the end of the femur, drain, and suture the skin. 

AMPUTATION OF THE HIP JOINT. 

"Primary amputation of the hip comes under consideration in any 
extensive crush of the thigh or gunshot injury, but offers hardly any 
chance whilst the primary shock exists. 

''The better plan is to try and check the hemorrhage, clean the 
wound as much as possible, pack with gauze and wait. The patient 
having rallied from the shock, and gangrene, sloughing and necrosis 
being imminent, amputation is indicated with a fair prospect of saving 
life. * * * The first step is to control hemorrhage. * * * But there is 
one method safe and applicable to all cases and especially when the 
surgeon is unaccustomed to the operation, and that is to divide the 
common femoral vein and artery, each between two ligatures. 
There is then no further bleeding, except from the region of the 
crucial anastomosis behind, the vessels forming which are easily picked 
up and divided." 

Formation of the Flaps. — "From the lowxr end of the longitudinal 
incision for tying the vessels, a circular incision is continued around 
the thigh, the skin flaps retracted and the soft parts divided as ampu- 
tation of the thigh." (Walsham's Surgery.) 

Sennas Bloodless Amputation at the Hip Joint. — First incision: with the 
pelvis resting on the lower edge of the table, make a straight incision 
(beginning about three inches above the great trochanter) about eight 
inches in length, directly over the center of the great trochanter, 
and parallel to the long axis of the limb. When the knife reaches the 
great trochanter, its point should be kept in contact with the bone 
the whole length of the remaining part of the incision. 

The margins of the w^ound are now retracted and any spurting ves- 
sels secured. 

The trochanteric muscular attachments are now severed close to 
the bone with a stout scalpel. The clearing of the digital fossa and 
the division of the obturator externus tendon, require special care. 
The thigh is now flexed, strongly abducted, rotated inward, when 
the capsular ligament is divided transversely, at its upper and posterior 



646 



SOME PRACTICAL AMPUTATIONS. 



aspect. The remaining portion of the capsular ligament is severed, 
while the thigh is brought back to a position of slight flexion, after 
which it is rotated outward and, if possible, the ligamentum teres is cut. 
If this cannot be done, the head of the bone is forcibly dislocated upon 
the dorsum of the ilium by flexion, adduction and rotation of the thigh. 
The trochanter minor and upper part of the shaft of the femur are 
cleared by using a scalpel and periosteal elevator alternately. At 
the completion of this part of the operation, the femur is in a position 




Fig. 538. — Elastic constriction completed by constricting the posterior segment of 
the thigh. Flaps formed, including all the tissues down to the muscles. (Senn.) 



of extreme adduction and the upper portion projects some distance 
from the wound. 

If the surgeon has kept in close contact with the bone and has used 
the knife sparingly and the periosteal elevator freely, the hemorrhage 
has been slight. 

E astic constriction is now applied. Bring the limb down in a 
straight line with the body. A long straight hemostatic forceps is 
inserted into the wound behind the femur and on a level with the tro- 
chanter minor when in a normal position. The instrument is then 
pushed inward and downward two inches below the ramus of the is- 
chium and just behind the adductor muscles. As soon as the point 



SENN'S AMPUTATION AT THE HIP. 



047 



can be felt under the skin in this location, two inch incision is made 

through the skin, through which the instrument is made to emerge. 

After enlarging the tunnel made in the soft tissues by dilating the 

branches of the forceps, a piece of aseptic rubber tubing, three or 





















L 




/ <^ 


^ 


Ix 






/ ^ 






j . 




^-r**-" 


._^$J« i 




:'Pf/ 




t^ 


^P/ 







Fig. 539. — Senn's method, of performing bloodless amputation at the hip joint: Dislo- 
cation of head of femur and upper portion of shaft through straight external incision. 
Elastic constrictors in place: the anterior one tied. 



four feet in length, is grasped in the middle with the forceps and 
drawn along the tunnel as the forceps are withdrawn, whereupon 
the rubber tube is cut in two where it was held by the forceps. 
With one-half of the tube, the anterior segment of the thigh is con- 



648 SOME PRACTICAL AMPUTATIONS. 

stricted sufl&ciently firmly to intercept both the arterial and venous 
circulation completely. 

Before the constrictor is tied, the limb should be held in the vertical 
position long enough to render it practically bloodless. The elastic 
constrictor is either tied, or, still better, held with a forceps at the 
point of crossing. 

The posterior segment of the thigh is constricted by the remaining 
half of the tube, which is drawn sufficiently tight behind; the 
ends of the tube are made to cross each other and are brought forward 
and made to include the anterior segment, when they are again firmly 
drawn and tied, or otherwise fastened above the first constrictor, 
furnishing an additional security against hemorrhage from the larger 
vessels in the anterior flap, when cut during the amputation (Fig. 538). 

After the principal blood vessels have been tied, the posterior con- 
strictor is removed and additional bleeding points are secured before 
the anterior constrictor is removed (Fig. 539). 

Surface compression with a compress wrung out of hot, normal salt 
solution, is a valuable aid in minimizing the hemorrhage, after the 
removal of the constrictors. 

"As this method of controlling hemorrhage does not require the 
presence of a skilled assistant, it will prove of especial value in emer- 
gency cases. The operation can be performed with the instruments 
contained in every pocket case. Should an elastic tube not be at 
hand, the constriction can be made .in a satisfactory manner by sub- 
stituting a cord made of sterile gauze, tightened with a lever of some 
kind, as is done in applying the ordinary Spanish windlass." (Senn, 
Practical Surgery.) 

The amputation is completed by cutting antero-posterior flaps as 
shown in Fig. 538. 



CHAPTER XXII. 

DILATATION OF THE SPHINCTER ANI ; OPERATION FOR 
PILES ; OPERATION FOR FISTULA. 

DILATATION. 

Temporary paralysis of the anal sphincter is the preliminary step 
to most of the interventions on the rectum, and may be of itself suffi- 
cient for the cure of fissures. 

The patient should be purged the day preceding the operation; and 




Fig. S40. — Dilatation of the rectum. (Veau.) 

the rectum should be washed out with soap and water, preliminary to 
the actual operation. 

General anesthesia is almost indispensable and it needs to be pro- 
found, for the anal reflex is one of the last to yield. Spinal anesthesia 
is often useful in anal operations. 

In the absence of a special dilator, begin by inserting tlie two thumbs 

649 



650 



DILATATION OF THE SPHINCTER ANI. 



back to back, and bracing the fingers against the outer surface of the hips, 
stretching the sphincter by rhythmic movements of the thumbs, grad- 
ually increasing the force. There is no danger of overdilatation so con- 
tinue until the thumbs are in contact with the ischial tuberosities (Fig. 
540). Drainage is indicated in simple dilatation for fissure. 

Employ either one large or two or three small tubes well wrapped 




Fig. 541.— Drainage after dilatation. (Veau.) 

with iodoform gauze soaked in cocainized vaseline (vaseline thirty 
parts, cocaine one part), in order that the subsequent pain may not 
be so severe (Fig. 541). The tubes may be removed on the second 
day and the bowels moved on the third. 



OPERATION FOR HEMORRHOIDS. 

Most cases of piles are curable by local and constitutional treat- 
ment; however, those that are very large, bleeding and inflamed, re- 
quire an operation for their removal and radical cure. 

There are several methods of procedure, many of which are success- 
ful, none dangerous and quite within the scope of every practitioner. 



OPERATION FOR PILES. 



651 



The following may be recommended in those cases in which the 
marginal tumors are well defined but not pedunculated: — 

Begin by a careful cleansing of the bowel by purgation and lavage. 
Three days before the operation, give a free purge and prescribe a 
liquid diet. Prescribe an enema each morning and evening for the 
next two days. On the day preceding the operation, it is a good idea to 
check peristalsis with a small dose of opium. 

Employ general anesthesia. Carefully cleanse the peri-anal region 
and scrub the rectum with soap and water. Dilate the anus, as pre- 





FiG. 542. — Making the first 
incision. (Veau.) 



Fig. 54 s. — Passing the first 
suture. (Veau.) 



viously described. Fasten the pile tumor with a forceps, and at its 
lower end, make a short curved incision (Fig. 542). The incision 
involves only the skin, which is to be loosened from the underlying 
structures by a little blunt dissection. Suture this part of the skin before 
proceeding further, using a small curved needle armed with a No. 2 
catgut. Tie the suture moderately tight and leave the threads long 
for a landmark, which will be appreciated later on. Pass two or three 
sutures in this manner, depending upon the length of the incision 
(Fig. 543)- 
Again prolong the incision on either side a little way and detach. 



652 



DILATATION OF THE SPHINCTER ANI. 



by blunt dissection, the lips of the wound from the veins beneath, by 
which means a sort of pedicle is formed (Fig. 544). This pedicle con- 
sists of a part of the veins which are to be ligated and excised. 




\ n 




Fig. 544- — Freeing the veins by blunt dissec- Fig. 545- — Ligation of the first vas- 
tion. (Veau.) cular pedicle. (Veau.) 





Fig. 546. — Burying the pedicle by suture. Fig. 547. — Ligation of the last vascular 

(Veau.) pedicle. (Veau.) 



Pass a ligature around a part of the veins (Fig. 545) and tie. Divide 
the ligated veins to the outer side and cut the ligatures short. 

Now, pass a suture so as to enclose and cover in the stump (Fig. 546). 



OPERATION FOR PILES. 



653 



Again prolong the original incision on each side of the base of the 
tumor and expose more of the pedicle; ligate, excise and suture as be- 
fore, until finally the upper pole of the tumor is reached, and the last of 
the pedicle tied off (Fig. 547). 

The terminal sutures enclose the last stump of the pedicle and com- 
plete the repair of the incision at the same time (Fig. 548). 

It is better to proceed thus from below upward in order that the 
blood, always considerable, will flow downward and mask only the 
field already sutured. 





Fig. 548. — Applying the last 
sutures. (Veau.) 



Fig. 549. — Treatment of ulcerated 

piles by cautery. (Veau.)' 



The line of incision must follow closely the base of the tumor, for 
if the edges of the wound are too widely separated, the strain may cause 
the sutures to tear out. 

If the whole of the anal circumference is involved, it is necessary to 
treat in the manner described, the two sides only. 

Do not disturb the anterior and posterior poles of the anal border, 
although, if necessary, those points may be touched up with the thermo- 
cautery. 

Place drainage tubes wrapped with iodoform gauze saturated in 
vaseline, as described under the head of dilatation of the sphincter. 

The suusequent pain is always severe and will require a hypodermic 
injection of morphia. Retention of urine is often present. The ex- 



654 



DILATATION OF THE SPHINCTER ANI. 



ternal dressings should be changed daily and liquid diet maintained for 
five or six days and the bowels kept under restraint. Do not be con- 
cerned with the swelling. 

On the sixth day, remove the drainage tube; on the seventh, open the 
bowels with castor oil, and instruct the patient to cleanse carefully the 
anal region after each movement. 

The sutures will be absorbed and if none give way too soon, the 




Fig. 550. — Laying open the track of fistula on the grooved-director. (Veau.) 



healing will be complete in about two weeks; otherwise there may be 
a raw surface which will need to be dressed a little longer. 

In certain cases there is no well defined tumor, but the surface is 
ulcerated, infected and exceedingly painful, and is unaffected by patient 
local treatment. 

In such a case, the thermo-cautery will probably give the best results. 
For one or two days the patient is kept in bed and a moist dressing ap- 
plied which will diminish the swelling. 

Employ general anesthesia, cleanse and dilate the anus. The ther- 
mo-cautery is heated to a dull red. Pressed into the tumor, it loses its 



CAUTERIZATION OF ULCERATED PILES. 655 

glow (Fig. 549). Reheat it and reapply a short distance from the point 
of application, and in this manner proceed until the pile has been well 
punctured. It is not necessary to puncture deeply. Apply drainage 
and a moist dressing. The subsequent pain is always severe and must 
be controlled by a hypodermic of morphia. There may be retention of 
urine requiring relief by catheterization. The dressing must be renewed 




Fig. 551. — Cauterization of the diverticula of the fistula. (Veau.) 

twice daily. The eschar will drop off between the fourth and eighth 
day, and the bowels should be moved about the eighth day. The cure 
will be complete in about a month. 

OPERATION EOR ANAL FISTULA. 

A grooved director is passed through the fistulous tract and emerg- 
ing in the rectum, its point is caught by the finger in the rectum and 
brought outside the anus. The whole length of the tract is laid open 

(Fig. 550)- 

The diseased tissues are then curetted or touched with the cautery 
(Fig. 551). Pack with gauze until repair by granulation is complete. 



I 



CHAPTER XXIII. 

PHIMOSIS; PARAPHIMOSIS; CIRCUMCISION; 
HYDROCELE; CASTRATION. 

PHIMOSIS. 

Phimosis may be congenital or acquired, though it is much more 
frequently the former. There is usually present one or both of two 
conditions: a redundant prepuce with contracted orifice; or a frenum 
so short as not to permit retraction without marked bowing of the organ. 

The disturbances produced by congenital phimosis are due either to 
mechanical interference or reflex irritability, although, of course, many 
cases of phimosis seem to give rise to no symptoms. The mechanical 
interference may lead to infection, balanitis or even urethritis, or to 
straining which may be the origin of an inguinal or umbilical hernia; 
the straining may also produce prolapsus ani or hydrocele by pressure 
on the spermatic vessels. 

The reflex symptoms, often due perhaps to the adhesions of the 
prepuce to the glans, are numerous and varied, the most common being 
disturbances of micturition, erethrism, and functional nervous derange- 
ments. 

Every case of phimosis, therefore, should receive attention, in infancy, 
and in general, the only treatment worth while is circumcision. 

The acquired phimosis of adult life, most often due to acute infec- 
tive inflammations, is usually to be relieved by antiseptic washes and 
treatment addressed to the septic cause. 

PARAPHIMOSIS. 

Paraphimosis has its origin in certain malformations, traumatism, 
or inflammations, and appears in many degrees of severity. In some 
cases it is easily reduced; in others, irreducible without an operation 

There is always the danger, in severe and neglected cases, of ul- 

656 



PARAPHIMOSIS. 657 

ceration, sloughing or gangrene. The appearances are more or less 
constant: the exposed glans is swollen and reddened; behind it is a 
collar of congested, mucous membrane; behind this a deep furrow in 
which lies the constricting band; and behind this, another band of 
swollen integument. 

An effort must be made at once to reduce the foreskin. The re- 
duction is always painful. Begin by thoroughly cleansing and cocain- 
izing the parts. Apply a compress saturated with a twenty per cent 
solution of cocaine and then wait ten minutes. 

Smear a little vaseline on the balano-preputial furrow, but not over 
the glans generally, else the manipulating fingers will slip. 

The purpose is to apply a slow, firm and progressive pressure to the 




• Fig. 552. — Reducing a paraphimosis. (Stewart.) 

engorged tissues, at the same time making traction forward on the fore- 
skin and pressure backward on the glans. 

There are several ways of doing this, of which the following is an 
excellent method: grasp the penis behind the glans, between the 
first and second fingers of each hand, and while these make compression 
and traction, the two thumbs are braced against the apex of the glans 
(Fig. 552). 

After reduction is accomplished, measures must be employed to sub- 
due the inflammation and the patient advised of the necessity for a 
circumcision later, to insure against a recurrence. 
42 



658 



PARAPHIMOSIS. 



If reduction cannot be accomplished by these measures, an operation 
must be done without delay. The purpose is to divide the restricting 
band, which lies in the groove between the two ridges. 

Inject a little cocaine along the line of incision which is usually in 
the middle line of the dorsum and just behind the corona (Fig. 553). 

Use the point of the knife, making short, firm, shallow cuts, until the 
constricting band is felt to yield. A too bold incision may result in 
seriously wounding the corpora cavernosa. 

The bleeding in any event will usually be free but ceases spontane- 




FiG. 553. — Dividing the constricting band in paraphimosis. (Veau.) 



ously. The wound which at first was vertical, becomes transverse 
when reduction is completed, and is sutured in that direction. 

Apply a moist dressing and if there is no ulceration or gangrene, the 
swelling will soon subside. But in this case also, the patient must be 
advised of the danger of recurrence unless a circumcision is done for 
the relief of the narrowed prepuce or the short frenum, after the inflam- 
mation has subsided. 



OPERATION FOR CIRCUMCISION. 



CIRCUMCISION. 



659 



This is an excellent operation, probably not often enough done in 
infancy, when it is simple and without danger, and may prevent the 
disturbances of adolescence, consequent upon phimosis. 

In adult life, it is often the primary step toward the relief of acute 
disorders and sexual irregularities. 

The Operation. — General anesthesia is nearly always indicated in 
children; local, in adults. To secure local anesthesia, begin by lightly 
tamponing the perputial orifice with a pledget of cotton saturated 




Fig. 554. — Resection of the prepuce. (Veau.) 



with a ten per cent solution of cocaine, and left in position for at 
least five minutes. Next inject the foreskin in the line of the proposed 
incision, using a four per cent solution of cocaine or Schleich's solution. 
The too rapid absorption of cocaine may be prevented by constriction 
of the base of the penis. 

When the anesthesia is established, break up the preputial ad- 
hesions with a grooved director or probe, usually not difficult in an 
infant but sometimes difficult in the adult, following balanitis. 

There are various methods of making the incision, any of which, 
properly employed, will give good results. Suppose the prepuce is long 
and slender: begin by holding the penis vertically and ivithont making 



66o 



CIRCUMCISION. 



traction on the foreskin, apply a forceps so that its blades lie parallel 
with the oblique line of the corona (Fig. 554). Use care, of course, 
not to pinch the glans. Divide the foreskin with the bistoury, allow- 
ing the blade to hug the upper side of the forceps, that no bruised tis- 
sues may be left behind. The skin retracts, leaving the mucosa cover- 
ing the glans. Divide this mucous covering along the middle line to 
within one-fifth inch of the coronal border (Fig. 555). The glans 
will now be completely exposed. 

Trim off the two mucous flaps so that a narrow cuff is left. It is 
better to begin near the frenum and trim toward the terminal point of 




Fig. 



-Splitting the mucous membrane. (Veau.) 



the dorsal incision (Fig. 556). If the frenum is too short, divide it 
transversely with the scissors (Fig. 557), catching up the little artery 
which will be divided. This completes the necessary incisions. 

Hemostasis must be assured. It may be necessary to tie two or 
three small vessels and nearly always the artery of the frenum re- 
quires ligation, using catgut No. i. 

A brief application of adrenalin solution on a compress will check the 
oozing if it should persist. 

Suture. The mucous and cutaneous borders are brought into exact 
contact and united by several small, interrupted sutures of catgut (Fig. 



CIRCUMCISION. 



66i 




Fig. 556. — Resection of the mucous membrane. Fig. 557. — Section of the frenum. (Veau.) 
(Veau.) 





Fig 558. — Maintaining coaptation by means Fig. 559.— After section of the frenum the 
of a small clip. (Veau.) raw edges are coapted. (Veau.) 



662 CIRCUMCISION. 

558). The transverse incision of the frenum is made a vertical one by 
extending the glans, and is sutured in that direction (Fig. 559). 

In the case of children, it may be sufficient, instead of suturing, to 
use small clips, by which means, it is claimed, swelling is avoided. 

Dressing. — Wrap the penis in a sterile compress, leaving the glans 
exposed. Enclose the whole in a second compress perforated over the 
meatus, and secure with adhesive strips. 

Adults require bromides to prevent painful erections. The dress- 
ings are not to be changed unless soiled. Remove the sutures and 
re-dress the fifth day. It will probably require ten to twelve days for 
repair to be complete. 

Children usually need a daily change of dressing. If clips are 
used instead of sutures, they are to be removed at the end of twenty- 
four hours, and if the adjustment was perfect, the reunion by that time 
will often be practically complete. 

HYDROCELE. 

The chief test of a hydrocele is its "translucency." The first treat- 
ment usually tried is tapping, and the injection of an alterative. If 
the hydrocele recurs, then a radical operation should be done. Often 
this should be resorted to from the first without preliminary tapping 
especially in the long standing cases, where the tunica vaginalis is 
thickened and it is almost obvious that the trouble will recur. 

Occasionally the patient will prefer repeated simple puncture and 
evacuation without subsequent injection, rather than the more radical 
procedures which will lay him up for some days. 

Tapping. — Anesthesia is not necessary. Prepare the field as for a 
surgical operation. Seize the tumor behind with the left hand so as 
to make it tense in front. The trocar, held in the right hand with 
index finger an inch from the point to limit its penetration, is entered 
with a sharp thrust into the middle and lower part of the anterior 
surface of the tumor (previously assure yourself that the testicle is not 
inverted). Withdraw the plunger, being careful that the tube is not 
displaced. When the fluid is evacuated, attach a syringe to the trocar 
and inject a drachm of a one-half per cent solution of cocaine; gently 
massage the scrotum so as to bring the solution in contact with the 



OPERATION FOR HYDROCELE. 



663 



whole testicle, wait ten minutes and then let the solution flow- out. 

In the meantime charge the syringe with a drachm of pure tincture 
of iodine and inject. Hold it for five minutes and then let it escape. 
Withdraw the trocar and seal the puncture with collodion. 

The next day the scrotal wall is painful, reddened and swollen. 
The scrotum must be well supported, and moist compresses may give 
some relief. The patient should be kept in bed for ten days and 
warned that several weeks may be required^ for absorption of the ex- 
udates. 







Fig. 560. — Incision for hydrocele. (Veau.) 



RADICAL OPERATION. 

Sterilize the penis, scrotum and perineum. Wrap the penis in a 
sterile compress and have it held out of the way. 

Local anesthesia may be employed but a general anesthesia is better. 

Make an incision two inches long over the middle of the tumor, 
dividing first the several layers over the tunica (Fig. 560). Then open 
the tunica the whole length of the wound and evert the testicle. The 
tunica is stitched to the cord above and its free borders, brought to- 



664 



CASTRATION. 



gether behind the epididymis, are to be sutured to each other (Fig. 561). 
Or, the membrane may be resected completely, following close to the 
epididymis, and if the cut edges bleed, they are to be sewed with a con- 
tinuous suture (Fig. 562). 





Fig. 561. — Everting the tunica vaginalis. (Veau.) 



Restore the testicle, insert a small drain, and suture the scrotum. 
The drain should be removed on the second day and the sutures on the 
sixth, and in a day or two longer, the patient may get up. 

CASTRATION. 

The removal of the testicle is more frequently indicated as the 
result of cancer or tuberculosis, and may be done under either local or 
general anesthesia. 

The incision begins just below the external ring (on the right) and 
foUow^s the direction of the cord for from one and one-half to two 
inches (Fig. 563). 

Expose and isolate the cord up to the inguinal canal which, if in- 
volved, should be opened, as in the operation for hernia. Separate 
the different elements of the cord, so as to require two or three separate 



CASTRATION. 



665 





iG. 562. — Hydrocele: Resection of the tunica 
vaginalis. (Veau.; 



Fig. 563. — Incision for castration. 
(Veau.) 




Fig 564. — Ligation of the spermatic conl. (Veau.) 



666 CASTRATIOX. 

ligatures. Do not include the cremaster in the ligatures (Fig. 564). 
Just below the catgut ligatures, resect the cord and enucleate the tes- 
ticle from above downward (Fig. 565). 

This step is usually tedious in the tubercular cases on account of 
the adhesions which may have to be di\'ided with the bistoury, and 
the bleeding poi^ii-s tied. 




Fig. 565. — Separating the testicle from the scrotal tissues. (Veau.) 

Again inspect the cord (you have left the ligatures long till now) 
to be sure there is no bleeding; and it is recommended to cauterize the 
end of the vas in tuberculosis. 

Repair first the inguinal canal, if it was opened. Insert a drainage 
tube reaching to the bottom of the scrotum and projecting from the 
upper angle of the wound which is the point least likely to get infected 
after the dressings are applied. The tubercular cases, especially, 
require draiaage. Suture and apply a dry dressing. Remove the 
tube on the third dav and the sutures on the sixth or seventh. 



CHAPTER XXIV. 

INGROWING TOE-NAIL. 

The particular point in this operation is to obliterate the matrix 
corresponding to the part of the nail removed. It is insufficient to 
remove only that part of the nail gouging the flesh. Usually one side 
only is involved, the outer side, andjthej^removal of half the nail will 
effect a cure. 




Fig. 566. — Local anesthesia. (Veau.) 



Employ local anesthesia. Constrict the base and make a circular 
injection of cocaine or stovaine (Fig. 566). 

Remove the Nail. Introduce the sharp point of the scissors under the 
nail and divide its entire length (Fig. 567). Next seize the diseased 
portion with a forceps and tear it out (Fig. 568). 

Extirpate the Matrix. Incise the integument of the matrix to be 

667 



668 



INGROWING TOE-NAIL. 




Fig. 567. — Splitting the nail. (Veau.) 





Fig. 568. — Wrenching the nail out. (Veau.^) 




Fig. 569. — Incision over the matrix. (Veau.) Fig. 570. — Extirpation of matrix. (Veau.) 



IN-GROWING TOE-NAIL. 



669 



eliminated, with a sharp pointed bistoury, holding the cutting point 
obliquely, so that it gets a larger bite deeply than superficially (Fig. 569). 
The soft parts are thus removed down to the bone (Fig. 570). A deep 
cavity is left in the bottom, of which the bone may be seen (Fig. 571). 





Fig. 571. — The matrix removed. (Veau.) 



AM 

Fig. 572. — Wound sutured. (Veau.) 



This cavity should be packed with sterile gauze and allowed to heal by 
granulation, which will require two or three weeks. It is advisable 
to diminish the size of the cavity by a suture, including on one side 
the skin, and on the other, the subungual tissues (Fig. 572). It will 
probably give way finally, yet it facilitates repair. 



CHAPTER XXV. 
REMOVAL OF SMALL TUMORS. 

The technique for the removal of small tumors on or under the skin 
should be kept in mind. As in more difficult operations, a definite 
procedure should be followed. A lack of system may make a minor 
matter one of difficulty. 

Local anesthesia will usually suffice. It should be complete. To 
secure a complete local anesthesia, begin by determining the lines of 
incision and along these lines inject a two per cent solution of cocaine; 




Fig. 573. — Anesthesia of the skin. 
(Veau.) 



Fig. 5 74. 



-Anesthesia of the deeper layers. 

(Veau.) 



intradermic, not subcutaneous. If the tumor is large or if the skin is 
loose, redundancy may be avoided by making two semicircular in- 
cisions, thus removing an ellipse of the skin (Fig. 573). 

Next loosen the edges of the skin and partially expose the tumor 
and make a new injection along its sides. Later inject the base of the 
tumor as the dissection proceeds (Fig. 574). 

In the case of sebaceous cysts, the main point is to remove the sac in 
its entirety; anything else insures a return of the trouble. If possible, 

670 



REMOVAL OF SEBACEOUS CYSTS. 



671 



dissect the sac out without emptying its contents. The dissection 
will be done with ease only in case all the layers ate incised down to 
the true capsule. If the cyst walls are particularly thick, the contents 
may be emptied out from the first. 

Once the cyst is exposed retract one lip of the skin wound and loosen 




Fig. 575. — Detaching the capsule. (Veau.) 




Fig. 576. — Dissecting a loose capsule with the bistoury. (Veau.) 



the attachments by blunt dissection (Fig. 575). Or if the fibrous 
attachments are loose and tough, divide them with scissors or scalpel 
(Fig. 576). 

There will be some slight hemorrhage from the cavity following 
the removal of the cyst but it will be easily controlled by pressure or 



672 REMOVAL OF SMALL TUMORS. 

by a hot compress. In case the cyst was emptied in the course of the 
operation, be assured that all the cyst wall is removed, or the growth 
will recur. 

The procedure is the same in the case of a fatty tumor unless it is 
pedunculated; if so, make a curved incision on each side of its 
base. Usually a small blood vessel at the base of the tumor will 
require ligation. 

Synovial cysts require special attention to asepsis or the cavity with 
which they are connected, and from which they originate, may become 
infected; thus an arthritis or teno-synovitis might develop. The 
pedicle requires careful ligation. 

Branchial cysts are often intimately connected with the vessels 
in the neck and their dissection may be extremely difficult. The 
pedicle of such cysts usually terminates in the thyro-glossal duct. 

Angiomas are likely to give rise to dangerous hemorrhage. Only 
such as are small and well defined should be undertaken by the prac- 
titioner. No effort should be made to enucleate; instead elliptical 
incisions should be made quite beyond the borders of the tumor and 
the whole removed ''en masse." Usually a well-defined vascular 
pedicle will require careful ligation. 



CHAPTER XXVI 
SKIN GRAFTING. 

Skin grafting is a measure deserving to be more generally employed 
by the practitioner. Very often it would save time and trouble in the 
treatment of those conditions in which epidermitization is long de- 
layed, for this it hastens and also it tends to prevent the formation of 
scar tissue. Thus chronic ulcers, burns, and lacerated wounds 
followed by extensive sloughs may require grafting. 

The operation is simple in theory yet attended by many failures 
through lack of attention to detail. 

Three factors require the minutest supervision: (i) the field 
must be properly prepared; (2) the grafts must be cut correctly; 
(3) the after treatment must be appropriate. 

(i) The area to be grafted must be sterile and must be free of any 
oozing. If an ulcer is to be treated, the granulations must previously 
be made as healthy as possible: if sluggish, by curettement; if exuber- 
ant, by touching up with nitrate of silver. A few days afterward, it 
will be ready to receive the graft. A dry sterile dressing should be 
applied a day previous to the operation; before the graft is applied, 
the surface should be thoroughly douched with normal salt solution. 

(2) The skin which is to furnish the graft should be shaved and 
thoroughly scrubbed with soap and water. Antiseptics had better 
be avoided for they may compromise the vitality of the cellular ele- 
ments. A sufficient anesthesia may be obtained by injection of 
Schleich's solution No. 3. 

Two methods of cutting the grafts are currently employed, Rever- 
din's and Thiersch's. 

(I) Reverdin^s Method. — A small fold of the skin is picked up 

with fine tissue or mouse-toothed forceps and cut oft" at its base with 

small pointed scissors (Fig. 577). This section includes practically 

all the layers of the skin (Fig. 578). The graft is applied and gently 

43 673 



674 



SKIX GRArilXG. 



pressed out. Fifteen or twenty points are thus placed about fifteen 
mm. or say one-half inch apart. If the surface is large enough to require 




Fig. 5 7 7. — Manner of cutting the 
Reverdin graft. (Veau.) 



^*?^ 



Fig. 578. — The graft 
removed. (Veau.) 



more, the center should be left bare and treated by a second operation 

(Fig. 579)- 

(II) Thiersch's Method. — This method is the better when it succeeds, 
but the conditions of success are more exactinoj. Granulation tissue 




Fig. 5 79. — Placing Reverdin grafts. Ulcer of leg. (Veau.) 

usually needs to be removed by curettement, exposing the fibrous 
layer. The edges of the ulcer must be scraped (Fig. 580). The oozing 
which follows must be completely checked. A firm compress applied 



Thiersch's method. 



675 



for ten or fifteen minutes will usually sufi&ce. If oozing persists, the 
operation will fail. 




Fig. 580. — Thiersch's method: Preparing the wound for the graft. (Veau.) 

The grafts in this case consist of thin slices of the epidermis, as long 
as necessary and as wide as convenient. They are usually taken 




Fig. 581. — Cutting the Thiersch graft. (Veau.) 



from the anterior surface of the thigh. A sharp, thin-bladed razor 
is u.sed in cutting the slice (Fig. 581). 



676 



SKIN GRAFTING. 



The skin must be put on the stretch. Special retractors are occa- 
sionally employed. The two hands of the assistant and the left hand 
of the operator can make it sufficiently tense (Fig. 582). The razor 
is held nearly horizontally and cuts by a rapid, short, sawing motion. 
As the razor progresses, the thin and pliable tissue piles up on the 
blade. 




Fig. 582,— Cutting the Thiersch graft. (Veau.) 

The graft is now applied to the raw surface and the free end fixed by 
a pointed instrument and slowly -worked off the blade, and then 
teased out flat (Fig. 583). 

So proceed until the whole surface is covered. Small angles may 
be filled in with Reverdin grafts (Fig. 584). The area denuded need 
only to be covered with a sterile dressing and repair will soon be 
complete. 

(3) The grafted area must be carefully covered with strips of rubber 



y 



THIERSCH'S METHOD. 



677 



tissue or gutta-percha, placed in various directions so as to hold the 
grafts in place and at the same time give exit to any exudates. A 
layer of gauze saturated with salt solution is next applied, which in 
turn is covered by absorbent cotton, and the whole held in place by a 
moderately firm bandage. 





Fig. 583. — Method of applying the 
graft. (Veau.) 



Fig. 584. — Wound covered by 
grafts. (Veau.) 



The part should be immobilized, employing plaster splints if neces- 
sary. Change all the dressings except the rubber tissue every day or 
two and douche gently with normal salt solution. At the end of a 
week or ten days, change the tissue. 



INDEX 



Abdomen, contusions, 99 

gunshot wounds, 133, 145 

incised wounds, 103 

injuries, 99 

laparotomy, 102 

non-penetrating wounds, loi 

punctured w^ounds, 102 

stab wounds, 102 
Abdominal drainage, 104 

hemorrhage, 419 

section, 418 
Abscess, acute, 279 

alveolar, 287 

antrum, mastoid, 409 

appendiceal, 449 

Bartholin's gland, 312 

breast, 296 

cervical glands, 295 

chronic, 281 

definitions, 278 

dental, 287 

drainage, 281 

eyelids, 284 

external auditory meatus, 285 

face, 283 

floor of the mouth, 289 

iliac, 319 

ischio-rectal, 303 

kidney, 432 

labium, 312 

lachrymal, 285 

liver, 319 

lung, 392 

mammary, 296 

mastoid, 409 

nasal septum, 284 

palmar, 301 

parotid, 286 

pelvic, 314 

peri-anal, 306 

perineal, 307 

plantar, 303 

popliteal 301 



Abscess, prostatic, 307 

psoas, 319 

rectal, 306 

retropharyngeal, 292 

scalp subaponeurotic, 282 
subperiosteal, 283 
superficial, 282 

submaxillary, 288 

submammary, 298 

subphrenic, 317 

symptoms of, 279 

tongue, 291 

tonsillar, 291 

treatment, acute, 281 
chronic, 283 

urinary, 579 

vulvar, 312 

vulvo-vaginal, 312 
Acupressure, 50 
Acute intestinal obstruction, 456 

retention of urine, 565 
Actual cautery, phlegmon, 330 
Adrenalin chloride, epistaxis, 56 

shock, 44 
Air passages, foreign bodies, 358 

burns, 371 
Alcohol, antisepsis, 3 
Allison, strangulated hernia, 485 
Alveolar abscess, 287, 
Amputations, arm, 616 

atypical, 598 

Chopart, 631 

elbow, 616 

finger, 596 

foot, 633 

forearm, 612 

hand, 610 

hip-joint, 645 

index finger, 605 

knee joint, 641 

leg, 639 

little finger, 601 

little toe, 628 



679 



68o 



INDEX. 



Amputations, metacarpal, 6io 

metatarsal, 620 

middle finger, 600 

Pirogoff's, 635 

principles, 594 

Syme's, 638 
. thumb, atypical, 610 

thumb, typical, 607 

thigh, 643 

toes, 626 

scapulo-humeral, 625 

shoulder, 620 
Anal abscess, 306 

dilatation, 540 

fistula, 655 
Anastomosis, intestinal, 510 
Anderson, Cesarean section, 552 
Anesthesia, 10 

accidents, 13 

chloroform, 10 

cocaine, 16 

ether, 12 

ethyl chloride, 17 

local, 16 

spinal, 17 

stovaine, 16 
Aneurism, gunshot, no 
Aneurysmal varix, 112 
Angina, Ludwig's, 289 
Angiomas, 692 
Angus, torsion, 539 
Ankle amputation, 633 

arthrotomy, 347 

dislocation, 243 
Ankle, sprain, 248 
Anterior crural nerve, exposure, 270 

injury, 260 
Anterior tibial artery, ligation, 592 

nerve, injury, 275 
Antipyrine, epistaxis, 56 
Antiseptics, 3 
Antitetanic serum, 150 
Antistreptococcic serum, phlegmon, 

332 
Antrum, mastoid, 409 
Anus, abscess, 306 

artificial, permanent, 469 
temporary, 465 

dilatation, 540 

fistula, 655 

imperforate, 530 

•piles, 650 
Appendectomy, 441 
Appendiceal abscess, 449 



Appendicitis, 436 

after treatment, 453 
catarrhal, 439 
diagnosis, 436 
gangrenous, 439 
operation, 441 
perforating, 439 
treatment, 441 
ulceration, 439 
varieties, 438 
Appendix in hernia, 490 
Arm, amputation, 616 
bandages, -^y 
fractures, 175 
phlegmons, 330 
Aristol in burns, 369 
Arrest of hemorrhage, 49 
Arteries, ligations, rules, 584 
suture, 584 
torsion, 51 

wounds, gunshot, no 
Arterial hemorrhage, 46 
Artery forceps, 4 

ligation, anterior tibial, 592 
axillar}', 586 
brachial, 589 
common carotid, 586 
dorsalis redis, 593 
external carotid, 587 
femoral 591 
lingual, 587 
obturator, 272 
posterior tibial, 594 
radial, 590 
subclavian, 587 
ulnar, 591 
Artificial anus, permanent, 469 
temporar}', 465 
limbs, 639 
respiration, 14 
Arthritis, septic, 340 
Arthrotomy, 341 
ankle,' 347 
elbow, 348 
hip, 349 
knee, 341 
shoulder, 349 
wrist, 348 
Asphyxia, anesthesia, 13 
foreign bodies, 355 
retropharyngeal abscess 292 
Aspiration, bladder, 576 
pericardium, 395 
pleura, 390 



INDEX. 



68 1 



Astragalus, dislocation, 243 
Auditor}' nerve, injuries, 263 
Automatic centers paralysis, 31 
Axillary artery ligation, 586 
abscess acute, 298 
chronic, 300 

Bandage, Barton's, 38 

breast, 35, 

eye, 40 

finger, 36 

foot, 32 

groin, 34 

hand, 37 

head, 38 

knee, ^s 

leg, 33 

neck, 38 

shoulder, 38 

St. Andrew's cross, 34 

stump, 40 
Bandages, 28 

plaster, 40 
Bartholin's gland, abscess, 312 
Barton's bandage, 38 
Base of thorax, wounds, 96 
Bassinni, operation for hernia, 503 
Bavarian splints, 41 
Belfield, drainage of seminal ducts, 

311 . 
Bellocq's cannula, 57 
Bennett, Sir W., torsions, 538 
Bennett's fracture, 197 
Biceps tendon dislocation, 250 
Bi-coude, catheter, 506 
"Black eye," 60 

Bladder, aspiration in retention, 574 
Bladder, cystotomy, 575 

foreign bodies, 365 

hernia operation, 489 

gunshot wounds, 122 

puncture, 574 

rupture, 432 

suture, 433 

wounds, 432 
Bleeding (see hemorrhage) 
Bloodgood, intestinal obstruction, 456 

fractures, 171 
Blood vessels, injuries, 78-80 
Bolo wounds, 134 
Bone wiring, 196 
Bonney, emergency operations, 6 
Brachial artery, compression, 55 

ligation, 589 



Brain, abscess, 131 

compression, 158 

concussion, 157 

contusion, 158 

gunshot wounds, 117 

hemorrhage, 407 

injuries, 157 

topography, 401 
Branchial cysts, 672 
Breast abscesses, 296 

bandage, 35 
Bronchii, foreign bodies, 358 
Bronchoscopy, Killian, 360 
Brown, Cesarean section, 552. 
Bruises (see contused wounds) 
Bryant, esophagotomy, 379 
Bullard, trephining, 408 
Bullet wounds, civil, 142 

military, 109 
Bullets, types, no 
Burns and scalds, 366 
Burns, air passages, 370 
Burns, electrical, 371 
Burns, mouth, 370 

Caffeine in shock, 44 

Cahill, torsions, 538 

Calmette's antitetanic powder, 150 

Camphorated oil in shock, 44 

Cannaday, subcuticular suture, 24 

Capitellum, 39 

Carbuncle, 284 

Carpus, dislocation, 247 

fracture, 193 
Carotid artery compression, 54 

ligation, 586 
Castration, 654 

emergency, 106 
Catheterization equipment, 566 

" retrograde, 563 
Catgut, 19 

chromicized, 19 

iodized, 20 
Catheters, box for, 4 

sterilization, 566 
Cecum in hernia, 489 
Cerebro-spinal fluid, characters, 15^ 
Cervical glands, suppuration, 21)5 
Cesarean section, 550 
Championniere, fractures. 172 
Chest contusions, gi 

wounds, 93 
Cheyne, phlegmon of nock, 331 
Chloroform anesthesia, 10 



682 



INDEX. 



Chloroform anesthesia, face in, lo 

pulse in, lo 

pupil in, ID 
Chipman, reduction of shoulder, 229 
Chopart's amputation, 630 
Cigarette drain, 26 
Circular enterorrhaphy, 522 
Circumflex nerve, exposure, 269 

injury, 268 
Circumcision, 659 
Clark, appendicitis, 438 

intussusception, 462 
Clavicle, fracture, 165 
Cocaine anesthesia, 15 
Coley, femoral hernia, 515 
Collapse, 43 
Colles' fracture, 188 
Colon bacillus, 436 
Colostomy, 469 
Colpotomy, 314 
Comminuted fractures, 151 
Compound dislocations, 245 

fractures, 215 

ankle and foot, 218 
Compression of arteries, brachial, 55 

carotids, 54 

coronary, 54 

facial, 54 

occipital, 54 

subclavian, 54 

temporal, 54 

of brain, 158 
Concussion of brain, 159 
Condyles of humerus, fracture, 184 
Congenital hernia, 503 
Coin catchers, 356 
Conjunctiva, foreign bodies, 350 

wounds, 76 
Continuous suture, 20 
Contusions, 60 

abdomen, 99 

brain, 159 

chest wall, 91 

eye, 76 

eyelid, 60 

knee joint, 247 

lung, 92 

nerves, 261 
Cook, appendicitis, 442 
Corner, torsions, 542 
Coracoid process, examination, 179 
Coronary artery, compression, 54 
Cotton, injuries to testicle, 107 
Cranial nerves, injuries, 263 



Craniectomy, emergency, 400 

Crepitus, 171 

Crile, direct transfusion, 48 

shock, 45 
Crushing injuries to the extremities, 80 
Cushing, shock, 45 
Cut throat, 74 

wrist, 78 
Cystotomy, operation, 575 

Deep epigastric artery, 56 
Dental abscess, 287 
Depressed fracture, skull, 153 
Diaphragm, wounds, 96 
Digital arteries, compression, 55 
Dilatation of the anus, 649 

urethral stricture, 506 
Direct pressure in hemorrhage, 49 
Dislocations, 220 

ankle, 243 

compound, 245 

elbow, 234 

finger, 238 

hip, 238 

jaw, 234 

knee, 242 

shoulder, 220 

semilunar cartilages, 243 

thumb, 236 

wrist, 246 
Dixon, tubal pregnancy, 544 
Dorsalis pedis artery ligation, 593 
Dorsum ilii, dislocation, 238 
Double spica, 34 
Douglass, peritonitis, 455 
Downey, fracture of femur, 202 
Doyen's trephine, 404 
Drainage, 25 

abdominal, 104 

abscess, 281 

accidental wounds, 27 

amputations, 595 

appendicitis, 453 

arthrotomy, 341 

aseptic wounds, 28 

compound fractures, 27 

empyema, 27 

gauze wick, 26 

heart wounds, 387 

operative wounds, 27 

tubes, 26 

urinary infiltration, 584 
Dressings, 28 

first aid, 136 



INDEX. 



683 



Dupuytren's splint, 213 
Dura mater, wounds, 401 
Dutch cane splints, 125 
Dyspnea, heart wounds, 98 



Ear drum, paracentesis, 410 
Ear forceps, 352 
Ear, foreign bodies, 351 
Eastman, J. R., hernia, 511 
Eastman, T. B., appendicitis, 437 
Ectopic gestation, 543 
Edema of glottis, 376 
Elbow, amputation, 616 

arthrotomy, 348 

dislocation, 243 

fracture, 185 

gunshot wounds, 129 
Electrical burns, 371 
Elliott, wounds of kidney, 432 
Emergency antisepsis, 6 

operations, preparation, 6 

surgery, equipment, 2 
military, 148 
Emphysema, chest injuries, 91 
Empyema of thorax, 392 
adult, 395 
after treatment, 398 

child, 394 

diagnosis, 392 

puncture for, 393 
Enemas, technique, 458 
Enterostomy, 465 
Enterectomy, 519 
Enterorrhaphy, 522 
Epistaxis, 56 

Equipment, emergencies, 2 
Esmarch bandage, 50 
Esophagotomy, 378 
Esophagus, foreign bodies, 358 

wounds, 75 
Estes, intussusception, 460 
Ether anesthesia, 12 

adrenalin chloride in, 13 
External auditory meatus abscess, 285 

carotid artery ligation, 587 

urethrotomy, 558 
Extra-capsular fracture, 198 
Extravasation of urine, 579 
Extremities, wounds, yj 
Eye, foreign bodies, 75 
Eye injuries, 76 
Eyelid, abscess, 284 

contusion, 60 



Face, abscesses, 283 

fractures, 162 

furuncle, 283 

gunshot wounds, 162 
Facial artery, compression, 54 

nerve injuries, 262 

mastoid operation, 414 
Femoral artery, compression, 55 
ligation, 591 
stab wound, 78 

hernia, anatomy, 492 
radical cure, 513 
strangulated, 492 
taxis, 479 
Femur, amputations, 643 

fractures, 202 

osteo-myelitis, 339 
Fibula, fractures, 206 
Figure-of-eight bandage, 31 
Fingers, amputations, 596 

bandages, 36 

fractures, 194 

infections, 323 
First aid, dressing, 136 

fractures, 173-198 

hemorrhage, 53 

splints, 141 
Fiske, wounds of spleen, 431 
Fistula, anal, 655 

urinary, 555 
Floor of mouth, abscess, 289 
Foot, amputations, 630 

bandages, 302 

fractures, 218 
Forceps, artery, 4 

aural, 351 

nasal, 353 

urethral, 363 
Ford, ether anesthesia, 13 

fracture of patella, 203 
Foreign bodies, air passages, 358 

bladder, 364 

ear, 351 

esophagus, 354 

eye, 350 

larynx, 358 

nose, 353 

pharynx, 354 

rectum, 361 

trachea, 358 

urethra, 363 
Foxworthy, bolo wounds, 134 
Fractures, 151 

arm, 182 



684 



INDEX. 



Fractures, carpus, 193 

clavicle, 165 

compound, 215 

crepitus, 171 

definitions, 151 

diagnosis, 169 

extremities, 168 

face, 162 

gunshot, 131 

femur, 198 
gunshot, 127 

fibula, 206 

first aid, 173 

foot, 218 

forearm, 186 

gunshot, 128 

hand, 193 

head, 192 

humerus, 182 

jaw, lower, 163 
upper, 162 

leg, 206 

maxillae, 162 

metacarpus, 194 

nasal bone, 162 

olecranon process, 190 

patella, 203 

pelvis, 214 

radius, 186 

reduction, 172 

ribs, 165 

scapula, 213 

skull, 152 

supra-condylar, 192 

spine, 160 

tarsus, 218 

tibia, 206 

toes, 218 

ulna, 186 

wrist, 188 
Freezing, 371 
Frost bite, 371 



Gage, rupture quadriceps extensor, 251 
Gangrene, amputation, 594 
Gastric lavage, 13 
Gastro-enterostomy, 426 
Gauze, 3 

. dressings, 28 
General practitioner as emergency sur- 
geon, I 
Genito-crural nerve injury, 273 
Gibbon, suture of heart, 388 



Gunshot fractures, 128 

Gunshot wound of abdomen, 121, 133, 

145 

bladder, 122 

bone. III 

brain, 116, 130 

cranium, 114, 142 

face, 131, 144 

neck, 131 

head, 142 

heart, 121 

intestine, 121, 133, 147 

joints, 113, 129, 148 

kidney, 123 

knee, 130, 148 

liver, 123 

lungs, 120 

nerves, no 

pancreas, 123 

rectum, 122 

skull, 114, 130 

spine, 117 

spleen, 123 

stomach, 122 

thorax, 119, 132, 144 

trachea, 132 
Gunshot wounds, civil, 141 

eft'ects on tissues, 109 

hemorrhage, 109 

military, 109 

prognosis, 123 

shock, 109 

suicidal, 142 

treatment, 123 
Gun-splint, 141 
Granger, burns, 370 
Groin, bandage, 34 

Hand, abscess, 301 

amputations, 610 

bandages, 38 

brushes, 2 

fractures, 194 

infections, 325 

injuries, 85 

sterilization, 8 
Harsha, torsions, 538 
Hartmann, splenectomy, 542 
Havard, gunshot wounds, 120, 142 
Hayes, peritonitis, 453 
Haynes, wounds of liver, 427 
Head, wounds, 69 
Heart, gunshot wounds, 121 



INDEX. 



685 



Heart, massage, 14 

repair, 384 

suture, 387 
Hemarthrosis, 130, 149 
Hematoma, 60 
Hematuria, 432 
Hemopericardium, 91 
Hemoptysis, 89 
Hemorrhage, 46 

acupressure, 50 

adrenalin chloride, 47 

arterial, 46 

capillar}', 46 

constitutional effects, 46 

diagnosis, 47 

ectopic, gestation rupture, 544 

fatal, 47 

first aid, 53 

forcipressure, 51 

heat, 49 

hypodermoclysis, 48 

infusion, intravenous, 48 

internal, 46 

intermediary, 46 

kidney, 421 

liver, 421 

meningeal, 159 

mesentery, 421 
Hemorrhage, normal salt solution, 47 

parenchymatous, 46 

primary, 46 

secondary, 47 

spleen, 421 

spontaneous arrest, 49 

symptoms, 46 

torsion, 51 

tourniquets, 50 

treatment, 47 

tubal pregnancy, 544 

venous, 46 
Hemorrhoids, operations, 650 
Hemostasis, 49 
Hemothorax, 89 
Hernia, appendix, 490 

bladder, 489 

cecum, 488 

femoral, 513 

gangrenous, 485 

gluteal, 502 

inguinal, 503 

interstitial, 478 

lumbar, 502 

lung, 91 

obturator, 500 



Hernia, perineal, 502 
properitoneal, 478 
sciatic, 502 
stomach, 491 
strangulated, 474 
umbilical, 479 
radical cure, femoral, 513 
inguinal, 503 
umbilical, 480 
Hernio-laparotomy, 488 
Hilton, abscess, 300 
Hip- joint, arthrotomy, 349 
amputations, 645 
dislocations, 238 
gunshot wounds, 129 
Hodgen's splint, 128 
Humerus, fractures, 174 
gunshot, 127 
lower end, 182 
surgical neck, 180 
upper end, 178 
osteomyelitis, 339 
Hunt, tubal pregnancy, 549 
Hydrocele, 662 

radical operation, 663 
tapping, 662 

Ice, appendicitis, 441 
Iliac abscess, 319 
Ilio-inguinal nerve injury, 273 
Incised wounds, 67 

of wrist, 78 
Infected wounds, 67 
Inferior maxilla fracture, 163 
Infiltration of urine, 579 
Ingrowing toe-nail, 667 
Inguinal hernia, anatomy, 503 

radical cure, 503 

strangulated, 477 
Injuries, abdomen, 99 

thorax, 89 
Instruinents, emergency, 4 

cleansing, 5 

preparation, 7 
Intercostal artery hemorrhage, 56 
Interrupted sutures, 23 
Interstitial hernia, 478 

tubal pregnancy, 54S 
Intestinal anastomosis, 523 

obstruction, acute, 456 
gastric lavage, 457 
laparotomy, 459 
rectal enema, 456 
symptoms, 456 



686 



INDEX. 



Intestinal obstruction, treatment, 457 

resection, 519 
Intestines, suture, 423 

wounds, 421 
Intracapsular fracture, 198 
Intracranial hemorrhage, 401 
Intravenous infusion, hemorrhage, 48 

shock, 44 

technique, 48 
Intussusception, 456 
Iodized catgut, 20 
Ischio-rectal abscess, 303 

Jaw, dislocation, 234 

fracture, 163 
gunshot, 144 
Joints, contusions, 247 

dislocations, 220 
compound, 245 

gunshot wounds, 129-148 

hemorrhage into, 130-149 

injuries, 220 

incised wounds, 248 

punctured wounds, 247 

sprains, 248 

stab wounds, 247 

suppurations, 341 

Kelley, torsions, 535 
Kidney, abscess, 432 

hemorrhage, 421 

injuries 232 

removal, 431 

rupture, 430 

wounds, 430 
Killian, bronchoscopy, 360 
King, fracture of extremities, 169 
Kollman filiform guide, 570 
Kolmer, Cesarean section, 552 
Knee, amputation, 641 

arthrotomy, 341 

contusions, 247 

dislocations, 242 

gunshot wounds, 248 

puncture, 346 

sprains, 248 

stab wounds, 248 

wounds, 248 
Kyle, foreign body in nose, 355 

Labium, abscess, 312 
Lacerated wounds, 64 
Laceration of brain, 159 



Lachrymal abscess, 285 
Lanphear, Cesarean section, 551 
Laparotomy for Cesarean section, 550 

general technique, 417 

gunshot wounds, civil, 145 
military, 133 

intestinal obstruction, 459 

for traumatism, 417 
Laplace, peritonitis, 455 
Laryngotomy, 378 
Larynx, foreign bodies, 388 
Lateral anastomosis, intestine, 425 

sinus thro mb is, 414 
Lavage, gastric, 13 
Leg, amputations, 639 

bandage, 33 

fractures, 206 

osteomyelitis, 336 
Lejars, appendicitis, 441 

reduction of shoulder, 221 
thumb, 238 

rupture of the lung, 92 

splint for leg, 209 

preparations for operation, 6 
Lembert suture, 423 
Lichtenstern, torsion, 541 
Ligation en masse, 52 
Ligations, anterior tibial, 592 

axillary, 588 

brachial 589 

common carotid, 586 

dorsalis pedis, 593 

external carotid, 587 

femoral, 591 

lingual, 587 _ 

posterior tibial, 594 

radial, 590 

subclavian, 587 

ulnar, 591 
Lingual artery, ligation, 587 
Link, tracheotomy, 376 
Lipomas, removal, 672 
Lips, wounds, 72 
Liver, hemorrhage, 421 

injuries, 426 

suture, 427 
Local anesthesia, 5 
Lower jaw, dislocation, 234 
Luckett, Fourth-of-July injuries, 150 
Ludlow, wounds, diaphragm, 96 
Ludwig's angina, 289 
Lung, abscess, 392 

gunshot wounds, 120 

hernia, 95 



INDEX. 



687 



Lung, rupture, 92 
stab wounds, 92 
suture, 363 

Malar bone fracture, 163 
Mammary gland abscess, 296' 
Marsee, fracture of fingers, 194 

injuries to hand, 85 

suture of tendons, 255 
Martin, Cesarean section, 552 
Mastoid operation, 412 
Materials for sutures, 19 
Mayo, umbilical hernia, 587 
Mayor's sling, 168 
Maxilla, fractures, 163 
Meatus, foreign bodies, 351 
Median nerve exposure, 264 

injury, 263 
Meningeal hemorrhage, 159 
Metacarpals, fracture, 194 
Mesentery, hemorrhage, 420 

repair, 421 
McEwen, strangulated hernia, 491 
McFarland, antitetanic powder, 150 
McGrath, appendicitis, 442 
Middle meningeal artery hemorrhage, 

159 
Miller, pelvic abscess, 317 
Miller, kidney, injury, 432 
Mitchell, peritonitis, 453 
Morrison, wounds of eye, 75 
Mosetig-Moorhof bone wax, 334 
Mothe, dislocation of shoulder, 225 
Motor-oculi nerve injury, 263 
Mouth burns, 370 
Moynihan, intestinal anastomosis, 510 

purulent peritonitis, 453 
Murphy button, 525 

purulent peritonitis, 453 

suture of arteries, 585 
olecranon, 192 
Musculo-cutaneous nerve, 274 
Musculo-spiral nerve exposure, 268 

Nares, plugging, 57 
Nasal bone, fracture, 162 

septum abscess, 284 
Nassau, esophagotomy, 380 
Nausea, anesthesia, 11 
Neck, bandage, 38 

wounds, JT^ 
gunshot, 131 
Neff, rupture of urethra, 554 
Nelaton's line, 198 



Nephrectomy, 431 
Nerve, compression, 261 

contusion, 261 

grafting, 262 

suturing, 260 

wounds, 261 
gunshot, no 
Nerves, individual, 262 

anterior crural, 269 

auditory, 263 

circumflex, 268 

facial 262 

individual fifth, 263 

genito-crural, 273 

ilio-inguinal, 273 

laryngeal, 263 

median, 263 

motor oculi, 263 

musculo-cutaneous, 269 

musculo-spiral, 287 

obturator, 272 

optic, 263 

peroneal, 274 

phrenic, 263 

pneumogastric, 263 

popliteal, 274 

radial, 267 

sciatic, 273 

tibial anterior, 275 
posterior, 276 

ulnar, 265 
Noble, Cesarean section, 552 
Noetzel, wounds of spleen, 430 
Nose, foreign bodies, 353 
hemorrhage, 56 

Obturator artery ligation 272 

dislocation, 242 

hernia, strangulated, 500 

nerve, 272 
(Edema of the glottis, 376 
(Esophagotomy, ■1,'j'i 
(Esophagus, foreign bodies, 358 

injuries, "jt, 
Ointment of Reclus, 369 
Olecranon, fracture, 190 
Oliver, strangulated hernia, 491 

jaw fracture, 163 
Omentum, hemorrhage, 419 

resection, 514 

torsion, 542 
Open wounds of thorax, 93 
Operative wounds, 62 
Operation in pri\ate lunisos, 



INDEX. 



Opium, appendicitis, 441 

Os calcis, Pirogoff's amputation, 635 

Oschner, appendicitis, 442 

femoral hernia, 515 

torsion, 538 
Osteomyelitis, acute, ;^^^ 

femur, 339 

humerus, 339 

tibia, 336 
Ovarian cysts, torsion of pedicle, 535 

Pagenstecher, linen, 20 
Palmar abscess, 301 

arches, 55 
Panaris, 323 
Pancreas, gunshot wounds, 123 

injuries, 429 

suture, 429 
Paraphimosis, 656 
Parencentesis, eardrum, 410 

pericardium, 390 

pleura, 393 
Parotid gland abscess, 286 
Patella, dislocation, 243 

fracture, 203 

wiring, 203 
Pedicles, ligation, 535 
Pelvic abscess, 314 
Pelvis, fractures, 214, 
Penis, injuries, 105 
Peri anal abscess, 306 
Pericardium, paracentesis, 410 

.puncture, 410 

suture, 388 

wounds, 98 
Perineal abscess, 307 

bruises, 580 

section, 582 
Peritonitis, purulent, 439 

treatment, 453 

typhoid, 454 

septic, 440 
Peroneal nerve, 274 
Pfaff, appendicitis, 440 

tubal pregnancy, 548 
Phalanges, fractures, 257 
Pharynx, foreign bodies, 354 
Phimosis, 656 
Phlegmon, 322 

arm, 330 

fingers, 323 

forearm, 329 

neck, 331 

perineum, 579 



Phlegmon, tendon sheaths, 325 
Phrenic nerve, 263 
Picric acid, burns, 369 
Piles operation, 650 
Pinna, wounds, 71 
Pirogoff's amputation, 635 
Plantar, abscess, 303 
Plaster-of-Paris bandages, 41 

preservation, 4 

splints, 41 
Pleura, empyema, 392 

incision, 394 

puncture, 393 

wounds, 93 
Pneumogastric nerve, 263 
Pneumo-thorax, 90 
Poisoned wounds, 67 
Popliteal abscess, 301 

artery compression, 56 
Porter, treatment of wounds, 66 
Posterior nares, plugging, 57 
Posterior tibial artery, 594 
Posterior tibial nerve, 276 
Pott's fracture, 211 
Pregnancy, extra-uterine, 543 
Preparation, emergency operations, 6 

hands, 7 

skin, 8 
Primary hemorrhage, 489 
Probang, foreign bodies, 385 
Properitoneal hernia, 478 
Prostatic abscess, 307 
Psoas abscess, 319 
Pulse, abdominal injury, 100 

appendicitis, 438 

chloroform anesthesia, 4 

ether anesthesia, 12 

hemorrhage, 47 

shock, 43 
Puncture, bladder, 576 

knee joint, 347 

pericardium, 390 

pleura, 395 
Punctured wounds, 64 

Quadriceps extensor tendon, rupture 

251 
Quinsy, 211 

Radial artery ligation, 590 

synovial sheath drainage, 327 

Radius, fractures, 186 
gunshot, 127 

Ranzi, torsions, 536 



INDEX. 



Reclus, lacerated wounds, 85 

ointment. 364 
Rectal injections, 458 
Rectum, abscess, 306 

dilatation, 649 

foreign bodies, 361 

hemorrhoids, 650 

wounds, 107 
Recurrent laryngeal nerve, 263 
Reduction "en masse," 478 

dislocations, 220 

fractures, 171 

hernia, 477 
Removal of small tumors, 670 
Responsibility of general practitioner, 2 
Retention of urine, 565 
Retropharyngeal abscess, ,292 
Reverdin skin grafting, 675 
Ribs, fracture, 165 

resection, 394 
Robinson, shock, 45 
Rongeur forceps, 401 
Roux, femoral hernia, 518 
Royster, fracture of humerus, 181 
Rugine, 396 

Rupture, tubal pregnancy, 543 
Russ, fracture of thumb, 197 

Saber splint, 141 

Saline solution in hemorrhage, 47 

sepsis, 453 
Sayres' dressing, 166 
Scalds, 366 
Scalp, abscesses, 282 

arteries, 54 

hematoma, 154 

wounds, 69 
Scapula amputations, 625 

fracture, 213 
Schell, Cesarean section, 552 
Schleich's formulae, 17 
Sciatic nerve injury, 273 
Sclerotic wounds, 771 
Scrotum, injuries, 106 
Scudder, fracture of leg, 210 
Sebaceous cysts, removal, 670 
Secondary hemorrhage, 47 
Semilunar cartilages dislocation, 243 
Seminal ducts abscess 311 
Senn, first aid on battlefield, 135 

fracture of femur, 199 

hip joint amputation, 645 

intussusception, 460 
Septic arthritis 340 

44 



Septum nasi abscess, 284 
Shell wounds, 133 
Shock, 42 
Shoulder amputation, 622 

bandage, 38 

dislocations, 220 
fractures, 182 
Shrapnell wounds, 133 
Silk sutures, 19 
Silk-worm sutures, 20 
Skin grafting, 673 

preparation, 9 
Skull, bullet wounds, 114, 130 

fracture, base, 152 

fracture, base, 152 
compound, 155 
vault, 154 

trephining, 400 
Spence, shoulder amputation, 620 
Spermatic cord, ligation, 666 

torsion, 539 

vasectomy, 311 
Spica for breast, 35 

groin, 34 
Spinal anesthesia, 17 

cord injuries, 162 
Spine, fractures, 160 

gunshot wounds, 132 
Spleen, hemorrhage, 521 

injuries, 430 

removal, 430 

rupture, 430 
Splenectomy, 430 
Splint, Bavarian, 41 

Dupuytren's, 213 

first aid, 141 

Hodgen's, 128 
Splints, 28 

plaster-of -Paris, 41 
Sprains, 248 
St. Andrew's cross, 34 
Stab wounds, 63 

abdomen, 102 

heart, 389 

knee, 247 

thigh, 78 

thorax, 95 
Sterilization, dressings, 7 

hands, 9 

instruments, 9 

skin, 9 
Stomach, hemorrhage, 122 

hernia, 491 

suture, 426 



690 INDEX. 



i 



Stomach, wounds, 426 
Stewart, suture of heart, 389 
Strangulated hernia, 474 

complications, 487 

femoral, 492 

inguinal, 479 

obturator, 500 

taxis, 476 

umbilical, 495 
Stricture of urethra, 565 
Subclavian artery, compression, 54 

ligation, 587 
Subclavicular dislocation, 234 
Subcutaneous wounds, 59 
Subcuticular, suture, 24 
Subglenoid dislocation, 230 
Submammary abscess, 298 
Submaxillary abscess, 288 
Subphrenic abscess, 317 
Subpubic dislocation, 242 
Subspinous dislocation, 233 
Suicide, attempts, 142 
Superior maxilla fracture, 162 

thyroid artery ligation, 587 
Surgical dressings, 28 
Suture of arteries, 584 

heart, 387 

intestine, 423 

liver, 427 

lung, 383 

nerves, 260 

pancreas, 429 

tendons, 255 

ureter, 434 

wounds, 20 
Sutures, catgut, 20 

continuous, 20 

horse-hair, 20 

interrupted, 20 

Lembert, 20 

linen, 20 

methods and materials, 19 

quilted, 20 

sero-serous, 20 

silk, 19 

silk-worm -gut, 19 

subcuticular, 24 
Syme's amputation, C^iS 
Syncope, 47 
Synovial sheath suppurations, 325 

cysts, 672 

Tampon for intercostal hemorrhage, 56 
Tapping, hydrocele, 662 



Tarso-metatarsal, amputation, 630 
Tarsus, dislocations, 243 

fracture, 218 
Taxis, indications, 426 

technique femoral hernia, 429 
inguinal hernia, 477 
Taylor, empyema, 392 

fracture of humerus, 282 
Temporo-maxillary joint dislocation, .234 
Tendon, dislocations, 250 
divided, 253 

rupture, 250 

suture, 255 

wounds, 253 
Testis, removal, 654 

suture, 105 

wounds, 105 
Tetanus, bolo wounds, 134 

Fourth-of-July injuries, 150 

prophylaxis, 150 

punctured wounds, 64 
Thiersch, skin grafting, 676 
Thigh, amputations, 643 
Thoracotomy, indications, 381 

technique, 381 
Thorax, injuries, 89 
Throat, cut, y;^ 
Thrombosis, lateral sinus, 413 
Thumb, amputations, 607 

dislocations, 236 

fracture, 187 
Tibia, fractures, 206 

osteomyelitis, 336 

trephining, S37 
Tibial arteries, ligation, 593 
Toe-nail, ingrowing, 667 
Toes, amputation, 626 
Tongue, abscess, 291 

suture, 72 

wounds, 72 
Tongue-traction, asphyxia, 13 
Tonsil, abscess, 291 
Torsion, arteries, 51 

omentum, 542 

pedicle ovarian cysts, 535 
spleen, 541 

spermatic cord, 539 
Townsend, catheterization, 567 
Trachea, foreign bodies, 358 

gunshot wounds, 132 

incised wounds, '/^ 
Tracheotomy, after-treatment, 376 

indications, 372 

operations, ^j^ 



INDEX. 



691 



Tracheotomy, tubes, 372 
Travers, suture of the heart, 389 
Trephining, femur, 339 

fracture of skull, 400 

humerus, 339 

tibia, 336 
Trephine, Doyen, 404 

Gait, 404 
Tubercular, abscess, 281 
Turpentine, burns, 369 
Tunica vaginalis, resection, 663 
Tuttle, imperforate anus, 534 
Typhoid perforation, 454 
Tubal pregnancy, diagnosis, 544 

operation, 545 

rupture, 543 
Tumors, superficial, 670 

Ulna, fractures, 186 
Ulnar artery, ligation, 591 

nerve exposure, 265 
injury, 264 

synovial sheath, 327 
Umbilical hernia, strangulated, 495 

radical cure, 497 
Ureter, repair, 434 

wounds, 434 
Urethra, anatomy, 556 

foreign bodies, 363 

catheterization, 565 

contusions, 557 

rupture bulbous portion, 558 
Urethra, rupture, diagnosis, 555 

membranous portion, 564 

pendulous portion, 564 

symptoms, 555 

treatment, 558 
Urethral forceps, 363 
Urethrotomy, 558 
Urinary abscess, 579 
Urine, extravasation, 557 

retention, 565 

Van der Walker, emergency surgery, 6 
Vagina, abscess, 312 

injuries, 104 
Vagus nerve, 263 
Van Hook's, anastomosis, 435 
Valentine emergency, catheterization, 

567 
Vasectomy, 311 
Vault of skull fracture, 154 
Veins of liver, ligation, 427 
Venous hemorrhage, 46 



Vineberg tubal pregnancy, 544 
Vertebrae, fractures, 160 
Viscera, abdominal, rupture, 99 
Volvulus, 457 

Von Bergman, gunshot wounds, 114 
Vulvo-vaginal abscess, 312 
Vulvar abscess, 312 
injuries, 104 

Walker, fractures of femur, 200 
Wathen, wounds of liver, 427 
Whitman, fracture of femur, 200 
Wiring fractured fingers, 198 

olecranon, 191 

patella, 203 
Wounds, abdomen, loi 

aseptic, 61 

base of thorax, 97 

bladder, 432 

blank cartridge, 150 

bolo, 134 

cleansing, 64 

contused, 59 

diaphragm, 98 

drainage, 78 

dressings, 65 

eye, 76 

eyelids, Jt, 

extremities, JJ 

face, 72 

fingers, 85^ 

general principles, 59 

gunshot, civil, 141 
military, 109 

hand, 85 

head, 69 

heart, 98 

hemorrhage, 61 

incised, 61 

infected, 61 

kidney, 431 

lacerated, 64 

lips, 72 

liver, 427 

lung, 426 

neck, 72, 

operative, 62 

pancreas, 429 

penis, 105 

pericardium, 98 

pinna, 71 

pleura, 93 

punctured, 64 

rectum, 109 



692 


INDEX. • -^x 


Wounds, scalp, 69 


Wounds, toy pistols, 150 ^^~- 


scrotum, 105 


ureter, 434 


special regions, 70 


vagina, 104 


spleen, 430 


vulva, 104 


stomach, 426 


wrist, 78 


subcutaneous, 60 


Wrist, arthrotomy, 348 


suture, 20 


dislocation, 246 


testicle, 105 


fractures, 188 


thigh, 78 
thorax, 89 
treatment, 64 


X-ray, foreign bodies, 356 
fractures, 171 


tongue, 72 


Zone of anesthesia, 15 



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